Form Ssa 10 Bk PDF Details

Navigating through the complexities of social security benefits after the loss of a spouse can be a challenging task. The Social Security Administration's SSA-10-BK form serves as a critical tool in this journey, offering a pathway for widows and widowers to apply for insurance benefits. This form not only facilitates the application for widow's or widower's insurance benefits under Title II of the Federal Old-Age, Survivors, and Disability Insurance Act but also extends to Health Insurance for the Aged and Disabled under Part A of Title XVIII of the Social Security Act. Furthermore, it encompasses potential entitlements under the Railroad Retirement Act and Veterans Administration payments for survivors, underlining its broad scope. The SSA-10-BK form requires detailed information about both the deceased and the applicant, spanning from personal identification details to specific inquiries about the deceased's employment history, military service, and previous marriages. As such, it stands as a gateway to ensuring financial assistance and stability for those navigating the aftermath of a spouse's death, emphasizing the importance of understanding and accurately completing this comprehensive document.

QuestionAnswer
Form NameForm Ssa 10 Bk
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesssa 10 form ssa 10 bk

Form Preview Example

SOCIAL SECURITY ADMINISTRATION

TEL

TOE 120/145/155

Form Approved

 

 

OMB No. 0960-0004

APPLICATION FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS*

(Do not write in this space)

 

I apply for all insurance benefits for which I am 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.

*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). If you were receiving benefits as a wife/husband at the time of your spouse's death, you need complete only the circled items. All other claimants must complete the entire form. For additional information about this application a fact sheet to Form SSA-10-BK is available at www.socialsecurity.gov.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

(a) PRINT name of deceased wage earner or

 

 

 

 

FIRST NAME, MIDDLE INITIAL, LAST NAME

 

 

 

 

 

 

 

self-employed person (herein

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

referred to as the "deceased")

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) Check (X) one for the deceased

 

 

 

 

 

 

 

 

 

 

u

 

 

 

 

 

 

 

Male

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(c) Enter deceased's Social Security Number

 

 

 

 

 

 

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

(a) PRINT your name

 

 

 

u

FIRST NAME, MIDDLE INITIAL, LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) Enter your Social Security Number

 

 

 

 

 

 

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(c) Enter your name at birth if different

 

 

 

 

FIRST NAME, MIDDLE INITIAL, LAST NAME

 

 

 

 

 

 

 

from item 2(a)

 

 

 

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART I -- INFORMATION

ABOUT THE DECEASED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Enter date of birth of deceased

 

 

 

 

 

 

 

 

 

u

MONTH, DAY, YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

(a) Enter date of death

 

 

 

 

 

 

 

 

 

 

 

u

MONTH, DAY, YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) Enter place of death

 

 

 

 

 

 

 

 

u

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.

 

 

 

 

 

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

(a) Did the deceased ever file an application for Social Security benefits, a

 

 

 

u

 

 

 

Yes

 

 

 

 

No

 

period of disability under Social Security, supplemental security income, or

 

 

 

(If "Yes," answer

(If "No," go on

 

hospital or medical insurance under Medicare? If unknown, check this box

 

 

 

 

 

 

 

(b) and (c).)

to item 7.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) Enter name(s) of person(s) on whose Social

 

 

 

 

FIRST NAME, MIDDLE INITIAL, LAST NAME

 

 

 

 

 

 

 

Security record(s) other application was

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

filed.

 

 

 

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(c) Enter Social Security Number(s) of person(s) named

 

in (b).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If unknown, check this block

 

 

 

 

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 or

 

 

Yes

No

 

 

conditions at the time of death?

 

 

 

 

 

u

(If "Yes," answer

(If "No," go on

 

 

 

 

 

 

 

 

 

 

 

(b).)

to item 8.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) Enter the date the deceased became unable to work.

 

u

MONTH, DAY, YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

(a) Was the deceased in the active military or naval service (including

 

 

Yes

No

 

 

 

 

Reserve or National Guard active duty or active duty for training) after

(If "Yes," answer

(If "No," go on

 

 

September 7, 1939 and before 1968?

 

 

 

 

 

 

 

 

 

 

 

u

 

 

(b) and (c).)

to item 9.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) Enter dates of service.

 

 

 

 

 

 

 

 

(Month, year)

(Month, year)

 

 

 

 

 

 

 

u

FROM:

TO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(c) Has anyone (including the deceased) received, or does anyone expect to

Yes

No

 

 

receive, a benefit from any other Federal agency?

 

 

 

 

 

 

 

 

 

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form

SSA-10-BK (06-2010) EF (06-2010)

Page 1

 

 

 

(Over)

Destroy Prior Editions

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?

 

 

u $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) About how much did the deceased earn the year before death?

 

 

 

 

Amount

 

 

 

 

 

u $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. (a) Did the deceased have wages or self-employment income covered

 

 

 

Yes

No

 

 

 

(If "Yes," skip to

(If "No," answer

 

under Social Security in all years from 1978 through last year?

 

 

u

 

 

 

 

 

 

 

item 11.)

(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.

 

u

 

 

 

 

 

 

 

 

 

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".)

Spouses'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

 

If spouse deceased, give date of death

Clergyman or public official

 

(or age)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Explain in Remarks)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

so indicate)

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(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

 

If spouse deceased, give date of death

Clergyman or public official

 

age)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Explain in Remarks)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

so indicate)

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USE "REMARKS" SPACE ON BACK PAGE FOR INFORMATION ABOUT ANY OTHER PREVIOUS 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?

 

 

u

 

PART II -- INFORMATION ABOUT YOURSELF

Yes

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

No

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

 

u

 

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

 

 

Yes

No

Unknown

 

age 5?

 

 

u

 

 

 

 

 

 

 

 

 

 

 

 

(c) Was a religious record of your birth made before

 

 

Yes

No

Unknown

 

age 5?

 

u

 

 

 

 

 

Form SSA-10-BK (06-2010) EF (06-2010)

Page 2

 

 

 

15.INFORMATION ABOUT YOUR MARRIAGE(S)

(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)

Date of death

Clergyman or public official

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Explain in Remarks)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(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 of death

Clergyman or public official

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Explain in Remarks)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(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 of death

 

Clergyman or public official

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Explain in Remarks)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

Yes

No

 

when the deceased died?

 

 

u

 

(If "Yes," skip to item 17.)

(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?

 

 

u

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 an application for

 

Yes

No

 

Social Security benefits, a period of disability under Social Security,

u

(If "Yes," answer (b)

(If "No," go on

 

 

 

 

 

supplemental security income, or hospital or medical insurance under Medicare?

 

and (c).)

to item 18.)

 

 

 

 

 

 

 

 

(b) Enter name of person on whose Social Security record

 

 

 

 

 

you filed other application

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(c) Enter Social Security Number of person named in (b).

(if unknown, so indicate)

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form SSA-10-BK (06-2010) EF (06-2010)

Page 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Over)

 

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, unable to

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

work because of illnesses, injuries or conditions?

 

 

 

u

(If "Yes," answer

(If "No," go on to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) .)

item 19.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) Enter the date you became unable to work.

 

 

u

(Month, day, year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. Were you in the active military or naval service (including Reserve or

 

 

 

 

 

 

 

 

 

National Guard active duty or active duty for training) after September

Yes

 

No

 

7, 1939 and before 1968?

 

 

 

 

 

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. Did you or the deceased work in the railroad industry for 5 years or

 

 

 

Yes

 

No

 

 

 

 

 

more?

 

 

 

 

 

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. (a) Did you or the deceased have Social Security credits (for

 

 

 

Yes

 

No

 

 

 

 

 

 

example, based on work or residence) under another country's

 

 

 

(If "Yes,"

(If "No," go on to

 

 

Social Security System?

 

 

 

 

 

u

 

 

 

 

 

 

 

answer (b).)

item 22.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) If "Yes," list the country(ies).

 

 

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22. (a) Have you qualified for, or do you expect to qualify for, a

 

 

 

Yes

 

No

 

 

pension or annuity (or a lump sum in place of a pension or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

annuity) based on your own employment and earnings for the

 

 

 

(If "Yes," check

(If "No," go

 

 

Federal Government of the United States, or one of its States

 

 

 

which of the items

on to item 23.)

 

 

or local subdivisions? (Social Security benefits are not

 

 

 

in item (b) applies

 

 

 

 

 

government pensions.)

 

 

 

 

 

 

u

to you.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b)

 

I receive a government pension or annuity.

 

 

 

I have not applied for but I expect

 

 

 

 

 

 

 

 

 

 

 

 

 

 

to begin receiving my pension or

 

 

 

I received a lump sum in place of a government

 

 

 

annuity:

 

 

 

 

 

 

pension or annuity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I applied for and am awaiting a decision on my

 

 

 

 

 

 

 

 

 

 

 

 

(Month, 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 are not eligible for automatic enrollment in Medicare Part B, 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.

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)?

 

u

Yes

No

 

 

 

 

 

 

 

 

 

 

Form

SSA-10-BK (06-2010) EF (06-2010)

Page 4

 

 

 

 

 

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

 

 

NONE

 

ALL

 

you did not earn more than *$

 

in wages, and did not

 

 

 

 

perform substantial services in

self-employment. These months

 

 

 

 

 

 

 

 

are exempt months. If no months were exempt months, place an

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

"X" in "NONE." If all months were exempt months, place an "X"

 

Jan.

 

Feb.

Mar.

 

Apr.

 

in "ALL."

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

May

 

Jun.

Jul.

 

Aug.

 

*Enter the appropriate monthly limit after reading the instructions,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

"How Your Earnings Affect Your Benefits."

 

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

 

 

NONE

 

ALL

 

you did not or will not earn more than *$

 

in wages, and

 

 

 

 

 

 

 

 

did not or will not perform substantial services in

 

 

 

 

 

 

 

 

 

self-employment. These months are exempt months. If no

 

Jan.

 

Feb.

Mar.

 

Apr.

 

months are or will be exempt months, place an "X" in "NONE." If

 

 

 

 

 

 

 

 

 

 

 

 

all months are or will be exempt months, place an "X" in "ALL."

 

 

 

 

 

 

 

 

 

May

 

Jun.

Jul.

 

Aug.

 

*Enter the appropriate monthly limit after reading the

 

 

 

 

 

 

 

 

 

 

 

 

instructions, "How Your Earnings Affect Your Benefits."

 

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

 

NONE

 

ALL

 

you do not expect to earn more than *$

 

 

in wages, and

 

 

 

 

 

 

 

do not expect to perform substantial services in self-employment.

 

 

 

 

 

 

 

These months will be exempt months. If no months are expected

Jan.

 

Feb.

Mar.

 

Apr.

 

to be exempt months, place an "X" in "NONE."

If all months are

 

 

 

expected to be exempt months, place an "X" in "ALL."

 

 

 

 

 

 

 

May

 

Jun.

Jul.

 

Aug.

 

*Enter the appropriate monthly limit after reading the

 

 

 

 

 

 

 

 

 

 

instructions, "How Your Earnings Affect 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.

 

u

 

IF YOU ARE FULL RETIREMENT AGE OR OLDER, GO ON TO PAGE 6. OTHERWISE, PLEASE READ CAREFULLY THE INFORMATION ON PAGE 8 AND ANSWER ONE OF THE FOLLOWING ITEMS.

28.

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

 

u

 

 

(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.

 

 

u

(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.

 

 

 

u

 

 

 

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

Yes

No

 

 

benefits on your own earnings record?

u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form

SSA-10-BK (06-2010) EF (06-2010)

Page 5

 

(Over)

REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

 

SIGNATURE OF APPLICANT

Date (Month, day, year)

 

 

 

 

 

 

 

 

 

Signature (First name, middle initial, last name) (Write in ink)

Telephone number(s) at which you

 

 

 

 

may be contacted during the day

SIGN

 

 

 

__ __ __

HEREu

 

 

 

 

 

 

AREA CODE

 

 

 

 

 

 

 

 

 

 

FOR

 

Direct Deposit Payment Address (Financial

Institution)

OFFICIAL

 

 

 

 

 

Routing Transit Number

C/S

Depositor Account Number

 

No Account

USE ONLY

 

 

 

 

 

 

 

 

 

 

Direct Deposit Refused

 

 

 

 

 

 

Applicant's Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if different.)

City and State

ZIP Code

Country (if any) in which you now live

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the applicant must sign below, giving their full addresses. Also, print the applicant's name in the Signature block.

1. Signature of Witness

2. Signature of Witness

Address (Number and street, City, State and zip Code)

Address (Number and street, City, State and zip Code)

Form SSA-10-BK (06-2010) EF (06-2010)

Page 6

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY WIDOW'S OR WIDOWER'S INSURANCE BENEFITS

 

BEFORE YOU RECEIVE A

SSA OFFICE

DATE CLAIM RECEIVED

 

NOTICE OF AWARD

 

 

TELEPHONE NUMBER(S)

 

 

 

TO CALL IF YOU HAVE A

 

 

 

QUESTION OR SOMETHING

AFTER YOU RECEIVE A

 

 

TO REPORT

NOTICE OF AWARD

 

 

Your application for Social

Security benefits

has

been

In the meantime, if you change your address, or if

there is some other change that may affect your

received and will be processed as quickly as possible.

claim, you--or someone for you--should report the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

change. The changes to be reported are listed on

You should

hear

from us

within

 

days

after

you

page 8. Always give us your claim number when

writing or telephoning about your claim.

have given us all the information we requested. Some

 

 

claims may

take

longer

if additional

information is

If you have any questions about your claim, we will

needed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

be glad to help you.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMANT

 

 

 

 

 

DECEASED'S SURNAME IF

SOCIAL SECURITY CLAIM

 

 

 

 

 

 

DIFFERENT FROM CLAIMANT'S

NUMBER

PRIVACY ACT NOTICE

Collection and Use of Personal Information

Sections 202, 205 and 223 of the Social Security Act, as amended, authorize us to collect the information requested on this form. The information you provide will be used to make a decision on this claim. Your response is voluntary. However, failure to provide the requested information may prevent an accurate and timely decision on any claim filed, or could result in the loss of benefits.

We rarely use the information provided on this form for any purpose other than for determining entitlement to Social Security benefits. However, in accordance with 5 U.S.C. § 552a(b) of the Privacy Act, we may disclose the information provided on this form in accordance with approved routine uses which include, but are not limited to, the following: 1. To enable an agency or third party to assist Social Security in establishing rights to Social Security benefits and/or coverage; 2. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State and local level; 3. To comply with Federal laws requiring the disclosure of the information from our records; and 4. To facilitate statistical research, audit or investigative activities necessary to assure the integrity of SSA programs.

We may also use the information you provide when we match records by computer. Computer matching programs compare our records with those of other Federal, State or local government agencies. Information from these matching programs can be used to establish or verify a person’s eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.

A complete list of routine uses for this information is contained in our System of Records Notice 60-0089 (Claims Folders Systems). Additional information regarding this form and other systems of records notices and Social Security programs are available from our Internet website at www.socialsecurity.gov or at your local Social Security office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED REPORT TO YOUR LOCAL SOCIAL SECURITY OFFICE, THE

NEAREST U.S EMBASSY OR CONSULATE OFFICE. You can find your local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U.S. Government agencies in your telephone directory or you may call 1-800-772-1213 (TTY 1-800-325-0778) for the address. You may send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the

completed report.

Form SSA-10-BK (06-2010) EF (06-2010)

Page 7

(Over)

CHANGES TO BE REPORTED AND HOW TO REPORT

FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES

uYou change your mailing address for checks or residence. (To avoid delay in receipt of checks you should ALSO file a regular change of address notice with your post office.)

uYour citizenship or immigration status changes.

uYou go outside the U.S.A. for 30 consecutive days or longer.

uAny beneficiary dies or becomes unable to handle benefits.

uWork Changes -- On your application you told us you

expect

total earnings for

 

to be $

 

.

You

 

(are)

 

(are not) earning wages of more than

 

 

 

 

$a month.

You (are) (are not) self-employed rendering substantial services in your trade or business.

(Report AT ONCE if this work pattern changes.)

u Change of Marital Status - Marriage, divorce, annulment of marriage. You must report marriage even if you believe that an exception applies.

uYou are confined to jail, prison, penal institution or correctional facility for conviction of a crime or you are confined to a public institution by court order in connection with a crime.

uCustody Change - Report if a person for whom you are filing, or who is in your care dies, leaves your care or custody, or changes address.

uYou begin to receive a government pension or annuity (from the Federal government or any State or any political subdivision thereof) or your pension or annuity amount changes.

uYou have an unsatisfied warrant for your arrest for a crime or attempted crime that is a felony (or, in jurisdictions that do not define crimes as felonies, a crime that is punishable by death or imprisonment for a term exceeding 1 year.)

FIGURING YOUR ANNUAL EARNINGS

uYou have an unsatisfied warrant for a violation of probation or parole under Federal or State law.

Disability Applicants

1.You return to work (as an employee or self- employed) regardless of amount of earnings.

2.Your condition improves.

WORK AND EARNINGS

For those under full retirement age, the law requires that a report of earnings be filed with SSA within 3 months and15 days after the end of any taxable year in which you earn more than the annual exempt amount. You may contact SSA to file a report. Otherwise, SSA will use the earnings reported by your employer(s) and your self-employment tax return (if applicable) as the report of earnings required by law and adjust benefits under the earnings test. It is your responsibility to ensure that the information you give concerning your earnings is correct. You must furnish additional information as needed when your benefit adjustment is not correct based on the earnings on your record.

HOW TO REPORT

You can make your reports by telephone, mail, or in person, whichever you prefer.

If you are awarded benefits, and one or more of the above change(s) occur, you should report by:

uCalling us TOLL FREE at 1-800-772-1213;

uIf you are deaf or hearing impaired, calling us TOLL FREE at TTY 1-800-325-0778; or

uCalling, visiting or writing your local Social Security office shown at the phone number and address on your claim receipt.

For general information about Social Security, visit our web site at www.socialsecurity.gov.

To figure your total yearly earnings, count all gross wages (before deductions) and net earnings from self-employment which you earn during the entire year. This includes earnings both before and after retirement, and applies to all earned income whether or not covered by Social Security.

In figuring your total yearly earnings, however, DO NOT COUNT ANY AMOUNTS EARNED BEGINNING WITH THE MONTH YOU ATTAIN FULL RETIREMENT AGE. Count only amounts earned before the month you attain full retirement age.

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE ANSWERING QUESTION 28.

Benefits may be payable for some months prior to the month in which you file this claim (but not for any month before you reach age

60 (unless you are disabled)) if:

uYOU WILL EARN OVER THE EXEMPT AMOUNT THIS YEAR.

(For the appropriate exempt amount, see "How Your Earnings Affect Your Benefits.")

If your first month of entitlement is prior to full retirement age, your benefit rate will be reduced. However, if you do not actually receive your full benefit amount for one or more months before full retirement age because benefits are withheld due to your earnings, your benefit will be increased at full retirement age to give credit for this withholding. Thus, your benefit amount at full retirement age will be reduced only if you receive one or more full benefit payments prior to the month you attain full retirement age.

Form SSA-10-BK (06-2010) EF (06-2010)

Page 8

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Filling in segment 2 of Form Ssa 10 Bk

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