Ssa 4111 Form – Fill Out and Use This PDF

CERTIFICATE OF ELECTION FOR REDUCED WIDOW(ER)'S AND SURVIVING DIVORCED

SPOUSE'S BENEFITS

1.

PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

ENTER HIS OR HER SOCIAL SECURITY NUMBER

(Hereafter called "Worker")

2.

PRINT YOUR FULL NAME (First name, middle initial, last name)

ENTER YOUR SOCIAL SECURITY NUMBER (If "none" or

"unknown" so indicate.)

INFORMATION ABOUT REDUCED WIDOW(ER)'S AND SURVIVING

DIVORCED SPOUSE'S BENEFITS

The law requires that you complete and return this Certificate of Election if you wish to receive a reduced widow's, widower's or surviving divorced spouse's benefit and are at least age 62 and under full retirement age (FRA).

The following will affect the amount of your benefit:

•The month and year you elect to begin to receive benefits will determine the amount of your monthly payments which will continue at a reduced rate even after you reach FRA.

•Depending on your date of birth, the rate of reduction applied to your benefit amount can range from 19/40 to 19/56 of 1 percent times the number of months from the start of the reduced benefits until the month you reach FRA.

•If another beneficiary is entitled to a monthly survivor benefit on this Social Security number, your benefit may be reduced by the total family benefit payable in the month. The benefit paid to a surviving

divorced spouse will not affect the benefit amount paid to other family members who receive benefits on the same record.

INFORMATION ON HOW BENEFITS ARE AFFECTED IF THE DECEASED WORKER RECEIVED REDUCED RETIREMENT BENEFITS

If the deceased worker received retirement benefits before FRA, the maximum survivor's benefit is limited to the higher amount that the deceased worker would have received if still alive or 82.5 percent of the deceased worker's unreduced benefit. Because of this limit, delaying receipt of reduced benefits will not necessarily increase the monthly benefit amount payable. We will review your election in item 3 below to make sure that the month selected maximizes your benefit amount.

3. I elect to accept permanently reduced benefits as provided in Section 202			MONTH	YEAR
(q) of the Social Security Act, beginning with	"

Enter any month beginning with the month of the deceased worker's death up to, but not including the month you reach FRA provided that the month you choose is within the past 12 months.

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.

Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)

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

	Form SSA-4111 (11-2010) EF (11-2010)	(OVER)
	Destroy Prior Editions

Privacy Act Statement

Sections 202(e), (f) and (q)(3) (42 U.S.C. 402) of the Social Security Act , as amended, authorizes us to collect this information. The information you provide is used to determine whether you may be eligible to receive reduced benefits as a widow(er) or a surviving divorced spouse. Your response is voluntary.

However, failure to provide all or part of the requested information could prevent an accurate and timely decision on this claim.

We rarely use this information provided on this form for any other purpose other than for the reasons explained above. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following:

1.To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;

2.To comply with Federal laws requiring the release of information from Social Security records (e.g., to the General Accounting Office and Department of Veteran's Affairs);

3.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and,

4.To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and improvement of Social Security programs.

We may also use this information you provided in computer matching programs. Matching programs compare our records with records kept by 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 and administered benefit programs.

A complete list of routine uses for this information is available in Systems of Records Notice 60-0089. The notice, additional information regarding this form, and information regarding our programs and systems, are available on-line 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 2 minutes to read the instructions, gather the facts, and answer the questions. SEND OR

BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY

1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form SSA-4111 (11-2010) EF (11-2010) Destroy Prior Editions