Form Ssa 753 – Fill Out and Use This PDF

The SSA-753 Form, also known as the Statement Regarding Marriage, is a critical document utilized by the Social Security Administration (SSA) to verify marital information vital for determining eligibility for spouse's benefits under the Social Security Act. This form meticulously gathers details about the relationship between the worker (whose earnings record is under consideration) and the applicant, ensuring accurate entitlement decisions to spousal benefits. For those navigating the complexities of Social Security benefits, completing this form accurately is an essential step towards establishing eligibility.

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Form Ssa 753 PDF Details

In the complex and nuanced landscape of social security benefits, understanding each form's role and requirements is crucial for applicants and beneficiaries alike. The SSA-753 form, issued by the Department of Health and Human Services and approved under the Social Security Administration with an OMB No. 0960-0017, serves a specific purpose in this domain. Titled "Statement Regarding Marriage," this form demands a thorough and honest compilation of information regarding an individual's marital status and history. Its primary aim is to assist in determinations related to an applicant’s eligibility for spouse’s benefits under the provisions of Title II of the Social Security Act, as amended. This includes verifying the existence of a marital relationship and its acknowledgment within the community and by the individuals themselves. Respondents are asked to detail their relationship to the wage earner or self-employed person (the "Worker") and to the applicant, providing insights into the frequency and nature of their interactions, the public and personal recognition of their marital status, and any other marriages either party may have entered into. This form underscores the importance of transparency and accuracy, with a clear warning about the legal implications of providing false information. Given its voluntary nature, the SSA-753 emphasizes the need for cooperation in establishing the truth around marital relationships, ultimately impacting the determination of benefits. The Paperwork/Privacy Act Notice section further elaborates on the collection and usage of this information, reassuring applicants about the confidentiality and specific use cases of their provided data.

Question	Answer
Form Name	Form Ssa 753
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	SSA 753 ssa 3 marriage certificate form legisit

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DEPARTMENT OF HEALTH AND HUMAN SERVICES	TOE 420	Form Approved
Social Security Administration		OMB No. 0960-0017

STATEMENT REGARDING MARRIAGE

All questions must be answered or marked “Unknown.” If you need more space for answers, continue them under “Remarks” on reverse side.

PAPERWORK/PRIVACYACTNOTICE:The SocialSecurityAdministrationisauthorizedto collecttheinformationon this formunder section 216(h)(1) (A) ofthe Social Security Act. Giving us this information is voluntary. You do not have to do it, but your cooperation is needed to help establish the applicant's eligibility to Social Security benefits. The Social Security Administration will use the information on this form to determine if a marital relationship exists so that an accurate determination may be made regarding entitlement to spouse's benefits. We mayroutinely give out the information on this formwithout your consent for a variety ofreasons. These reasons are explained in the Federal Register. Ifyou would like more details about this,please get in touch with any Social Security office.

Print Name of Wage Earner or Self-Employed Person (Herein referred to as the “Worker”).

Enter His (Her) Social Security Number

Print Name of Applicant

I understand that this statement will be considered in Connection with an application by the applicant named above for payment of benefits under the provisions of Title 11 of the Social Security Act, as amended, based on the earnings of the worker named above.

Print Your Full Name (First name, middle initial, last name)

1 . What is your relationship to the worker? (Mother, child, cousin, etc.—if not related, state “None.”)

To the Applicant? (Mother, child, cousin, etc.—if not related, state “None.”)

2. How long have you known the worker?	The Applicant?

3.How often and on what occasions did you meet the worker?

The Applicant?

4.	To your knowledge, were (are) the worker and applicant generally known as	Yes	No
	husband and wife?	Yes	No
	husband and wife?

5.	Did (do) you consider them husband and wife?	Yes	No
		Yes	No
	Give facts and explain fully the reasons for your belief:

Did you hear them refer to each as husband and wife?	Yes	No

If “Yes,” when and where?

Form SSA-753 (10-84) Prior editions may be used until supply is exhausted

(OVER)

In your opinion, did (do) they maintain a home and live together as husband and wife?				Yes	No
If “Yes,” where and when?				Yes	No

CITY OR TOWN	STATE		DATES
CITY OR TOWN	STATE
		FROM--			TO--

To your knowledge, did they live together continuously? If “No,” explain.

Yes

To your knowledge,	has either the worker or the applicant entered into			any other marriage?	Yes	No
If “Yes,” give the following information regarding all such marriages:					Yes	No

STATE WHETHER			DATE AND PLACE	HOW MARRIAGE	DATE AND PLACE
WORKER OR		TO WHOM MARRIED	DATE AND PLACE	HOW MARRIAGE	MARRIAGE
WORKER OR		TO WHOM MARRIED	OF MARRIAGE	TERMINATED	MARRIAGE
APPLICANT			OF MARRIAGE	TERMINATED	TERMINATED
APPLICANT					TERMINATED

(This space may be used for explaining any answers to the questions. If you need more space attach a separate sheet.)

Remarks:

I know that anyone who makes a false statement or representation of a material fact for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law by fine, imprisonment or both. I affirm that all information I have given in this document is true.

SIGNATURE OF PERSON MAKING STATEMENT

Signature (First name, middle initial,	last name) (Write in	ink)	Date (Month, day, year)

			Telephone Number
SIGN
HERE				Area Code
HERE				Area Code
Mailing Address (Number and street,	Apt. No., P.O. Box,	or Rural Route)

City and State

ZIP Code

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the person making the statement must sign below, giving their full addresses.

1. Signature of Witness

2. Signature of Witness

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

Form SSA-753 (10-84)

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Form Ssa 753 conclusion process detailed (portion 1)

2. Once this segment is finished, it is time to include the required details in To your knowledge were are the, Yes, Yes, Give facts and explain fully the, Did you hear them refer to each, Yes, If Yes when and where, Form SSA Prior editions may be, and Over in order to go further.

As to Give facts and explain fully the and Yes, be sure that you do everything right here. These two are the most important ones in this page.

3. In this specific step, review In your opinion did do they, Yes, CITY OR TOWN, STATE, DATES, FROM, To your knowledge did they live, No explain, Yes, To your knowledge has either the, Yes, STATE WHETHER, WORKER OR APPLICANT, TO WHOM MARRIED, and DATE AND PLACE. Every one of these will need to be filled out with highest focus on detail.

TO WHOM MARRIED, Yes, and STATE WHETHER inside Form Ssa 753

4. Filling in Remarks, I know that anyone who makes a, SIGNATURE OF PERSON MAKING, Date Month day year, Signature First name middle, SIGN HERE Mailing Address Number, Telephone Number, Area Code, City and State, and ZIP Code is essential in the fourth section - make sure you devote some time and fill out each and every empty field!

Date Month day year, Remarks, and City and State inside Form Ssa 753

5. This document must be finalized by dealing with this area. Here there is a detailed set of fields that require correct details for your form usage to be faultless: Address Number and street City, Address Number and street City, and Form SSA.

A way to fill out Form Ssa 753 portion 5

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Form Ssa 753 – Fill Out and Use This PDF

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