Form Ssa 10 – Fill Out and Use This PDF

The SSA-10 form, officially known as the Application for Widow's or Widower's Insurance Benefits, serves as a critical tool in applying for survivor benefits under the Social Security Act. This application facilitates the process for individuals seeking to claim insurance benefits following the death of a spouse, including lump-sum death payments and potentially other benefits under certain conditions. Its completion is essential for accessing the financial support designed to assist those who have lost a partner, ensuring they receive all entitled benefits. For detailed instructions on filling out the SSA-10 form, click the button below.

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Form Ssa 10 PDF Details

Navigating the Social Security Administration's Form SSA-10, an essential document for individuals applying for widow's or widower's insurance benefits, reveals the comprehensive nature of this application process. This form serves not only as an application for insurance benefits under Title II, which encompasses Federal Old-Age, Survivors, and Disability Insurance, but also under Part A of Title XVIII for Health Insurance for the Aged and Disabled. Its detailed structure is designed to capture sufficient information for determining eligibility for a lump-sum death payment and potentially other benefits including those under the Railroad Retirement Act and Veterans Administration payments. Applicants find sections dedicated to providing information about the deceased, including their Social Security contribution history and military service, as well as pertinent details about the applicant's relationship to the deceased, their own work history, and marital background. Importantly, the form also addresses the possibility of receiving Medicare benefits, highlighting the interconnection between various government benefits following the loss of a spouse. Completion of this form requires thorough attention to detail, as it directly impacts the applicant's eligibility for benefits and the financial support they can receive during a challenging period of adjustment.

Question	Answer
Form Name	Form Ssa 10
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	ssa 10, social security ssa 10 form, form ssa 1099 social security statement, social security administration form ssa 10

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SOCIAL SECURITY ADMINISTRATION	Page 1 of 8
Form SSA-10 (10-2019) UF	Form Approved
Discontinue Prior Editions	OMB No. 0960-0004

	APPLICATION FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS*		(Do not write in this space)
With this application, you are applying for all insurance benefits for which you are eligible under
Title II (Federal Old-Age, Survivors, and Disability Insurance) and Part A of Title XVIII (Health
Insurance for the Aged and Disabled) of the Social Security Act as presently amended. The
information you furnish on this application will ordinarily be sufficient for a determination on the
lump-sum death payment. If you were receiving spouse's benefits at the time of your spouse's
death, you only need to complete the circled items. All other claimants must complete the entire
form.*This may also be considered an application for survivors benefits under the Railroad
Retirement Act and for Veterans Administration payments under title 38 U.S.C., Veterans Benefits,
Chapter 13 (which is, as such, an application for other types of death benefits under title 38).
1. (a) PRINT name of deceased wage earner or		FIRST NAME, MIDDLE INITIAL, LAST NAME
	self-employed person (herein referred to as
	the "deceased")
	(b) Check (X) one for the deceased	Male	Female

(c) Enter deceased's Social Security Number

2. (a) PRINT your name		FIRST NAME, MIDDLE INITIAL, LAST NAME
2. (a) PRINT your name

	(b) Enter your Social Security Number

	(c) Enter your name at birth if different	FIRST NAME, MIDDLE INITIAL, LAST NAME
	from item 2(a)

PART I - INFORMATION ABOUT THE DECEASED

3.	Enter date of birth of deceased	MONTH, DAY, YEAR

4.	(a) Enter date of death	MONTH, DAY, YEAR

	(b) Enter place of death	CITY AND STATE

5.	Enter name of the State or foreign country where the deceased had
	a fixed, permanent home at the time of death.
6.	(a) Did the deceased ever file an application for Social Security		Yes	No
	benefits, a period of disability under Social Security, Supplemental		(If "Yes," answer	(If "No," go
	Security Income, or hospital or medical insurance under Medicare?		(If "Yes," answer	(If "No," go
			(b) and (c).)	on to item 7.)
	If unknown, check this box		(b) and (c).)	on to item 7.)
	If unknown, check this box

	(b) Enter name(s) of person(s) on whose	FIRST NAME, MIDDLE INITIAL, LAST NAME
	Social Security record(s) other application
	was filed.

Answer Item 7 Only if the Deceased Died Prior to Full Retirement Age or Prior to 1 Year Past Full Retirement Age, and Within the Past 4 Months.

7. (a) Was the deceased unable to work because of illnesses, injuries		Yes	No
		(If "Yes," answer (b).)	(If "No," go on
	or conditions at the time of death?	(If "Yes," answer (b).)	(If "No," go on
			to item 8.)
	(b) Enter the date the deceased became unable to work.	MONTH,DAY,YEAR

8. (a) Was the deceased in the active military or naval service		Yes	No
	(including Reserve or National Guard active duty or active duty	(If "Yes," answer	(If "No," go on
	for training) after September 7, 1939 and before 1968?	(b) and (c).)	to item 9.)
	(b) Enter dates of service.	(Month, year)	(Month, year)
	(b) Enter dates of service.	FROM:	TO:
		FROM:	TO:

	(c) Has anyone (including the deceased) received, or does anyone	Yes	No
	expect to receive, a benefit from any other Federal agency?	Yes	No

Form SSA-10 (10-2019) UF			Page 2 of 8
ANSWER ITEM 9 ONLY IF DEATH OCCURRED WITHIN THE LAST 2 YEARS.
9. (a) About how much did the deceased earn from employment and		Amount
	self-employment during the year of death?	$
	(b) About how much did the deceased earn the year before death?	Amount
		$
		$
10. (a) Did the deceased have wages or self-employment income		Yes	No
	covered under Social Security in all years from 1978 through	(If "Yes," skip to	(If "No,"
	last year?	(If "Yes," skip to	(If "No,"
	last year?	item 11.)	answer (b).)
		item 11.)	answer (b).)
	(b) List the years from 1978 through last year in which the
	deceased did not have wages or self-employment income
	covered under Social Security.
11. CHECK IF APPLICABLE

I am not submitting evidence of the deceased's earnings that are not yet on his/her earnings record. I understand that these earnings will be included automatically within 24 months, and any increase in my benefits will be paid with full retroactivity.

INFORMATION ABOUT THE DECEASED'S MARRIAGE(S)

12.Answer this item ONLY if the deceased had other marriages.

(a)If the deceased married after his or her marriage to you, enter the information on the last marriage.

(If none, write "NONE".)

Spouse's Name (including maiden name)	When (Month, Day, and Year)	Where (Name of City and State)

How Marriage Ended	When (Month, Day, and Year)	Where (Name of City and State)

Marriage performed by	Spouse's date of birth (or age)	If spouse deceased, give date
Clergyman or public official		of death
Clergyman or public official
Other (Explain in Remarks)

Spouse's Social Security Number (If none or unknown, so indicate)

(b)If the deceased had any other marriages, and the marriage lasted at least 10 years or ended due to death of the spouse (whether before or after you married the deceased), enter the information below. If the deceased divorced then remarried the same individual within the year immediately following the year of the divorce, and the combined period of marriage totaled 10 years or more, include the marriage. (If none, write "NONE".)

Spouse's Name (including maiden name)	When (Month, Day, and Year)	Where (Name of City and State)

How Marriage Ended	When (Month, Day, and Year)	Where (Name of City and State)

Marriage performed by	Spouse's date of birth (or age)	If spouse deceased, give date
Clergyman or public official		of death
Clergyman or public official
Other (Explain in Remarks)

Spouse's Social Security Number (If none or unknown, so indicate)

USE "REMARKS" SPACE ON BACK PAGE FOR INFORMATION ABOUT ANY OTHER MARRIAGE AS DESCRIBED IN 12b.

13.Is there a surviving parent (or parents) who was receiving support from the deceased at the time of death or at the time the deceased became disabled under

Social Security Law?

Yes (If "Yes," enter the name and address in"Remarks.")

PART II - INFORMATION ABOUT YOURSELF

14. (a) Enter name of State or foreign country where you were born.

If you have already presented, or if you are now presenting, a public or religious record of your birth established before you were age 5, go on to item 15.

(b) Was a public record of your birth made before age 5? (If "yes", go to item 15.)	Yes	No	Unknown
(c) Was a religious record of your birth made before age 5?	Yes	No	Unknown

Form SSA-10 (10-2019) UF		Page 3 of 8
INFORMATION ABOUT YOUR MARRIAGE(S)
15. (a) Enter information about your marriage to the deceased.
Spouse's Name (including maiden name)	When (Month, Day, and Year)	Where (Name of City and State)

How Marriage Ended	When (Month, Day, and Year)	Where (Name of City and State)

Marriage performed by	Spouse's date of birth (or age)	If spouse deceased, give date
Clergyman or public official		of death
Clergyman or public official
Other (Explain in Remarks)

Spouse's Social Security Number (If none or unknown, so indicate)

(b) If you remarried after the marriage shown in 15.(a), enter information about the last marriage. (If none, write "NONE".)

Spouse's Name (including maiden name)	When (Month, Day, and Year)	Where (Name of City and State)

How Marriage Ended	When (Month, Day, and Year)	Where (Name of City and State)

Marriage performed by	Spouse's date of birth (or age)	If spouse deceased, give date
Clergyman or public official		of death
Clergyman or public official
Other (Explain in Remarks)

Spouse's Social Security Number (If none or unknown, so indicate)

(c)Enter information about any other marriage you may have had that lasted at least 10 years (see item 12(b) for counting consecutive multiple marriages to the same individual) or ended due to death of the spouse (whether before or after you married the deceased). (If none, write "NONE".)

Spouse's Name (including maiden name)	When (Month, Day, and Year)	Where (Name of City and State)

How Marriage Ended	When (Month, Day, and Year)	Where (Name of City and State)

Marriage performed by	Spouse's date of birth (or age)	If spouse deceased, give date
Clergyman or public official		of death
Clergyman or public official
Other (Explain in Remarks)

Spouse's Social Security Number (If none or unknown, so indicate)

*USE "REMARKS" SPACE ON BACK PAGE FOR INFORMATION ABOUT ANY OTHER MARRIAGE AS DESCRIBED IN 15c.

IF YOU ARE APPLYING FOR SURVIVING DIVORCED SPOUSE'S BENEFITS, OMIT 16 AND GO ON TO ITEM 17.

16.(a) Were you and the deceased living together at the same address when the deceased died?

Yes (If "Yes," go to

item 17.)

No No(If "No," answer (b).)


	(b) If either you or the deceased were away from home (whether or not temporarily) when the deceased died, give the
	following: Who was away?		Deceased	Surviving Spouse

Date last at home:		Reason absence began:			Reason you were apart at time of death:

If separated because of illness,		enter nature of illness or disabling condition.

17. (a) Have you (or has someone on your behalf) ever filed					Yes	(If "Yes," answer	No	(If "No," go to
	an application for Social Security benefits, a period of					(b) and (c).)		item 18).)
	disability under Social Security, Supplemental Security
	Income, or hospital or medical insurance under Medicare?

(b) Enter name of person on whose Social Security record you filed other application.

Form SSA-10 (10-2019) UF					Page 4 of 8
DO NOT ANSWER QUESTION 18 IF YOU ARE FULL RETIREMENT AGE OR OLDER. GO ON TO QUESTION 19.
18. (a) Are you, or during the past 14 months have you been,		Yes	(If "Yes," answer	No	(If "No," go on
	unable to work because of illnesses, injuries or conditions?	Yes	(b) .)	No	to item 19.)
	(b) Enter the date you became unable to work.	(Month, day, year)

19. Were you in the active military or naval service (including		Yes		No
	Reserve or National Guard active duty or active duty for	Yes		No
	training) after September 7, 1939 and before 1968?

20. Did you or the deceased work in the railroad industry for 5		Yes		No
	years or more?	Yes		No
21. (a) Did you or the deceased have Social Security credits		Yes	(If "Yes," answer	No	(If "No," go on
	(for example, based on work or residence) under another		(If "Yes," answer		(If "No," go on
	(for example, based on work or residence) under another		(b).)		to item 22.)
	country's Social Security System?
(b) If "Yes," list the country(ies)

22. (a) Have you qualified for, or do you expect to qualify
	for, a pension or annuity (or a lump sum in place of a pension		(If "Yes," check
	or annuity) based on your own employment and earnings for the		(If "Yes," check		(If "No," go on
		Yes	which of the items	No
	Federal Government of the United States, or one of its States		which of the items
			in item (b) applies		to item 23.)
	or local subdivisions that was not covered under Social		to you.)
	Security? (Social Security benefits are not		to you.)
	government pensions.)
	(b)
	I receive a government pension or annuity.	I have not applied for but I expect to begin
	I received a lump sum in place of a	receiving my pension or annuity:
	I received a lump sum in place of a
	government pension or annuity.
	I applied for and am awaiting a decision on my
	I applied for and am awaiting a decision on my		(Month, day, year)
	pension or lump sum.	(If the date is not known, enter "Unknown".)

MEDICARE INFORMATION

If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of Age 65 or older you could automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you live in Puerto Rico or a foreign country, you are not eligible for automatic enrollment in Medicare Part B, and you will need to contact Social Security to request enrollment.

COMPLETE ITEM 23 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER

Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other services that Medicare Part A doesn't cover, such as some of the services of physical and occupational therapists and some home health care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be determined when your coverage begins. In some cases, your premium may be higher based on information about your income we receive from the Internal Revenue Service. Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a letter explaining how to pay your premiums. You will also get a letter if there is any change in the amount of your premium.

You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug plans and when you can enroll visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare also can tell you about agencies in your area that can help you choose your prescription drug coverage. The amount of your premium varies based on the prescription drug plan provider. The amount you pay for Part D coverage may be higher than the listed plan premium, based on information about your income we receive from the Internal Revenue Service.

If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with
Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles and prescription co-
payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the
nearest Social Security office.
23.Do you want to enroll in the Medicare Part B (Medical Insurance)?	Yes	No

Form SSA-10 (10-2019) UF									Page 5 of 8
ANSWER ITEM 24 ONLY IF THE DECEASED DIED BEFORE THIS YEAR.

24.(a) How much were your total earnings last year?				$
				$

(b) Place an "X" in each block for each month of last year in which you did					NONE			ALL
not earn more than *$	in wages, and did not perform				NONE			ALL
substantial services in self-employment. These months are exempt
months. If no months were exempt months, place an "X" in "NONE."					Jan.	Feb.	Mar.		Apr.
If all months were exempt months, place an "X" in "ALL."
If all months were exempt months, place an "X" in "ALL."					May	Jun.	Jul.		Aug.
*Enter the appropriate monthly limit after reading the information,					May	Jun.	Jul.		Aug.

					Sept.	Oct.	Nov.		Dec.
"How Work Affects Your Benefits" (Publication No. 05-10069).					Sept.	Oct.	Nov.		Dec.
25. (a) How much do you expect your total earnings to be this year?				$


(b) Place an "X" in each block for each month of this year in which you did
not or will not earn more than *$		in wages, and did not or will			NONE			ALL
not perform substantial services in self-employment. These months are					NONE			ALL

exempt months. If no months are or will be exempt months, place an "X"
in "NONE." If all months are or will be exempt months, place an					Jan.	Feb.	Mar.		Apr.
"X" in "ALL."
"X" in "ALL."					May	Jun.	Jul.		Aug.
*Enter the appropriate monthly limit after reading the information, "How Work					May	Jun.	Jul.		Aug.

					Sept.	Oct.	Nov.		Dec.
Affects Your Benefits" (Publication No. 05-10069).					Sept.	Oct.	Nov.		Dec.
ANSWER ITEM 26 ONLY IF YOU ARE NOW IN THE LAST 4 MONTHS OF YOUR TAXABLE YEAR (SEPT.,
OCT., NOV., AND DEC., IF YOUR TAXABLE YEAR IS A CALENDAR YEAR).

26. (a) How much do you expect to earn next year?				$
				$
(b) Place an "X" in each block for each month of next year in which you do
not expect to earn more than *$		in wages, and do not expect			NONE			ALL
to perform substantial services in self-employment. These months will be					NONE			ALL

exempt months. If no months are expected to be exempt months, place
an "X" in "NONE." If all months are expected to be exempt months, place					Jan.	Feb.	Mar.		Apr.
an "X" in "ALL."
an "X" in "ALL."					May	Jun.	Jul.		Aug.
*Enter the appropriate monthly limit after reading the					May	Jun.	Jul.		Aug.

					Sept.	Oct.	Nov.		Dec.
information, "How Work Affects Your Benefits."					Sept.	Oct.	Nov.		Dec.
27. If you use a fiscal year, that is, a taxable year that does not end			Month

December 31 (with income tax return due April 15), enter here the
month your fiscal year ends.

IF YOU ARE FULL RETIREMENT AGE OR OLDER, GO ON TO ITEM 29. OTHERWISE, PLEASE READ CAREFULLY THE INFORMATION ON PAGE 8 AND ANSWER ONE OF THE FOLLOWING ITEMS.

28. After reading the information on page 8, check one of thefollowing:

(a) I want benefits beginning with the earliest possible month.

(b)I am full retirement age (or will be within 4 months) and I want benefits beginning with the earliest possible month, providing that there is no permanent reduction in my ongoing monthly benefits.

(c) I want benefits beginning with		. I understand that either a higher initial payment or a higher continuing
monthly benefit amount may be
	possible, but I choose not to take it.
ANSWER QUESTION 29 ONLY IF YOU ARE NOW AT LEAST AGE 61 YEARS, 8 MONTHS.

29. Do you wish this application to be considered an application for
retirement benefits on your own earnings record?			Yes	No

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social security ssa 10 blanks to consider

You should put down your particulars within the part Enter name of the State or, If Yes answer b and c, No If No go on to item, b Enter names of persons on whose, FIRST NAME MIDDLE INITIAL LAST NAME, Answer Item Only if the Deceased, a Was the deceased unable to work, Yes, If Yes answer b, If No go on to item, b Enter the date the deceased, MONTHDAYYEAR, a Was the deceased in the active, Yes, and If Yes answer b and c.

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The system will ask you for particulars to automatically submit the area c Has anyone including the, and Yes.

part 3 to completing social security ssa 10

The Form SSA UF ANSWER ITEM ONLY IF, Amount, b About how much did the deceased, Amount, a Did the deceased have wages or, b List the years from through, CHECK IF APPLICABLE, Yes, If Yes skip to item, No If No answer b, I am not submitting evidence of, INFORMATION ABOUT THE DECEASEDS, When Month Day and Year Where Name, How Marriage Ended, and When Month Day and Year box will be the place to insert the rights and obligations of both sides.

social security ssa 10 Form SSA UF ANSWER ITEM ONLY IF, Amount, b About how much did the deceased, Amount, a Did the deceased have wages or, b List the years from through, CHECK IF APPLICABLE, Yes, If Yes skip to item, No If No answer b, I am not submitting evidence of, INFORMATION ABOUT THE DECEASEDS, When Month Day and Year Where Name, How Marriage Ended, and When Month Day and Year blanks to fill

Complete the file by looking at these particular sections: Other Explain in Remarks, Spouses Social Security Number If, b If the deceased had any other, Spouses Name including maiden name, When Month Day and Year Where Name, How Marriage Ended, When Month Day and Year, Where Name of City and State, Marriage performed by, Clergyman or public official, Other Explain in Remarks, Spouses date of birth or age, If spouse deceased give date of, Spouses Social Security Number If, and USE REMARKS SPACE ON BACK PAGE FOR.

social security ssa 10 Other Explain in Remarks, Spouses Social Security Number If, b If the deceased had any other, Spouses Name including maiden name, When Month Day and Year Where Name, How Marriage Ended, When Month Day and Year, Where Name of City and State, Marriage performed by, Clergyman or public official, Other Explain in Remarks, Spouses date of birth or age, If spouse deceased give date of, Spouses Social Security Number If, and USE REMARKS SPACE ON BACK PAGE FOR fields to fill out

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