Ssa 754 F4 Form PDF Details

The Social Security Administration's Form SSA-754-F4 plays a critical role in the process of determining an individual's eligibility for insurance benefits under Title II of the Social Security Act. Tailored specifically to gather detailed information about an individual's marital relationship, this form demands a comprehensive disclosure of the dynamic between the parties involved, including their living arrangements, intentions at the outset of their relationship, and any shifts that may have occurred over time. It delves into the formal and informal acknowledgments of the relationship, probing whether the parties ever considered themselves legally married and if there was any anticipation of a ceremonial marriage. Alongside personal testimonies, it requires tangible evidence such as joint financial activities, shared residences, and mutual introductions to society at large. The directive underscores the significance of verifying marital status, as it directly impacts the determination of benefits. Encapsulating more than mere procedural formalities, the form serves a dual function: it is instrumental in the administrative assessment of benefit entitlements and enhances the integrity of Social Security programs through the rigorous evaluation of claims. Its comprehensive layout, which mandates a detailed recounting of the relationship from both parties, underscores the administration's commitment to thoroughness and accuracy in benefit determinations. Furthermore, the form's introduction and concluding sections, including detailed instructions and legal attestations by the applicant, reinforce the gravity and legal implications of the information being provided, illustrating the balance between bureaucratic requirements and the personal realities of applicants' lives.

QuestionAnswer
Form NameSsa 754 F4 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesform marital form, form security marriage form, security form marriage, ssa 754 f4

Form Preview Example

 

Form Approved

SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0038

STATEMENT OF MARITAL RELATIONSHIP (By one of the parties)

(Do not write in this space)

All items on this form requiring an answer must be answered or marked "Unknown."

I understand that the information given by me will be used in connection with an application filed for insurance benefits payable under Title II of the Social Security Act, as amended, based on the earnings of the wage earner or self-employed person named below.

Privacy Act Notice: Section 216(h), of the Social Security Act, as amended, authorizes us to collect this information. We will use this information to make a determination on your claim. Furnishing us this information is voluntary. However, failure to provide all or part of the information could prevent us from making an accurate and timely decision on your benefit eligibility. We rarely use the information you supply for any purpose other than for making a determination relating to benefit eligibility. 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 Government Accountability Office and Department of Veterans' 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 assure the integrity and improvement of Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security). We may also use the information you provide 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 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 available in Systems of Records Notices entitled, Claims Folder Record, 60-0089 and Master Beneficiary Record, 60-0090. These notices, 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.

1.

PRINT NAME OF WAGE EARNER OR SELF EMPLOYED PERSON

 

SOCIAL SECURITY NUMBER

 

 

 

 

 

2.

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

3. NAME OF PERSON WITH WHOM YOU WERE LIVING:

 

 

 

 

 

 

4.

WHEN DID YOU BEGIN LIVING TOGETHER IN A

WHERE DID YOU LIVE?

 

HUSBAND AND WIFE RELATIONSHIP?

 

 

 

 

 

MONTH

YEAR

CITY OR TOWN

STATE

 

 

 

 

 

 

5.

A. DID YOU LIVE TOGETHER CONTINUOUSLY SINCE THAT TIME?

Yes

No

 

If "No," give the periods of separation and the reasons why you did not live together.

B. Where have you lived together as husband and wife and for what periods of time?

CITY OR TOWN

STATE

 

DATES

FROM

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.DID YOU HAVE AN UNDERSTANDING AS TO YOUR RELATIONSHIP WHEN YOU BEGAN LIVING TOGETHER?

Yes No

A. If it was in writing, furnish a copy; if it was not in writing, what did you say to each other about your living together?

B. WAS THIS UNDERSTANDING LATER CHANGED?

Yes

No

 

 

If "yes," what were the changes and when and why were they made?

 

 

 

 

 

7. DID YOU HAVE AN UNDERSTANDING AS TO HOW LONG YOU WOULD LIVE TOGETHER?

Yes

No

If "yes," what did you say to each other about how long you would live together?

 

 

 

 

 

 

 

Form SSA-754-F4 (02-2016) UF (02-2016)

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Destroy Prior Editions

 

 

 

 

 

 

 

8. A. DID YOU HAVE ANY UNDERSTANDING AS TO HOW YOUR RELATIONSHIP COULD BE ENDED?

Yes

No

 

B. IF "YES," WHAT DID YOU SAY TO EACH OTHER ON THIS SUBJECT?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. A. DID YOU BELIEVE THAT YOUR LIVING TOGETHER MADE YOU LEGALLY MARRIED?

Yes

No

 

 

 

 

B. IF "YES," WHY DID YOU BELIEVE SO?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. A. WAS THERE AN AGREEMENT OR PROMISE THAT A CEREMONIAL MARRIAGE WOULD

Yes

No

 

 

 

 

ALSO BE PERFORMED IN THE FUTURE?

 

 

 

 

 

 

 

 

 

B. IF "YES," EXPLAIN WHY THE CEREMONY WAS NOT PERFORMED.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. A. WERE ANY CHILDREN BORN OF THIS RELATIONSHIP? Yes

No

 

 

 

 

 

 

B. IF "YES," LIST BELOW:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FULL NAME AT BIRTH

 

DATE OF BIRTH (OR AGE)

 

PLACE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. BY WHAT NAMES WERE YOU AND THE PERSON WITH WHOM YOU WERE LIVING KNOWN?

 

 

 

 

A. BEFORE YOU LIVED TOGETHER (MAN'S NAME)

B. BEFORE YOU LIVED TOGETHER (WOMAN'S NAME)

 

 

 

 

C. SINCE YOU LIVED TOGETHER (MAN'S NAME)

D. SINCE YOU LIVED TOGETHER (WOMAN'S NAME)

 

 

 

E. IF YOU BOTH DID NOT USE THE SAME LAST NAME AFTER YOU BEGAN LIVING TOGETHER, STATE THE REASONS.

13. A. AFTER YOU STARTED LIVING TOGETHER, WERE THERE ANY TAX RETURNS FILED, DEEDS OR CONTRACTS

 

EXECUTED, INSURANCE POLICIES TAKEN OUT, BANK ACCOUNTS OPENED UP, ETC?

Yes

No

 

B. IF "YES," GIVE THE FOLLOWING INFORMATION:

 

 

 

 

TYPE OF DOCUMENT

DATE MADE OUT

WERE YOU SHOWN AS THE

 

OTHER'S HUSBAND/WIFE?

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

14. A. DID YOU HAVE JOINT BUSINESS DEALINGS WITH OTHER PERSONS OR JOINT CHARGE

Yes

No

 

ACCOUNTS IN STORES?

 

 

 

 

 

 

 

 

B. IF "YES," GIVE THE NAMES AND ADDRESSES OF SUCH PERSONS OR STORES:

 

 

 

NAME OF PERSON OR STORE

ADDRESS

DATE OF TRANSACTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.A. HOW DID YOU INTRODUCE THE PERSON WITH WHOM YOU WERE LIVING TO RELATIVES, FRIENDS, NEIGHBORS, BUSINESS ACQUAINTANCES AND OTHERS?

B.HOW DID THAT PERSON INTRODUCE YOU TO RELATIVES, FRIENDS, NEIGHBORS, BUSINESS ACQUAINTANCES AND OTHERS?

Form SSA-754-F4 (02-2016) UF (02-2016)

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16.HOW WAS MAIL ADDRESSED TO YOU?

17.LIST BELOW THE NAMES OF YOUR AND THE OTHER PERSON'S EMPLOYERS AND NEIGHBORS WHO KNEW OF YOUR RELATIONSHIP:

18.LIST BELOW YOUR CLOSEST RELATIVES (other than children) WHO KNEW OF YOUR RELATIONSHIP:

 

NAME

ADDRESS

RELATIONSHIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.LIST BELOW THE CLOSEST RELATIVES OF THE PERSON WITH WHOM YOU WERE LIVING (other than children)

WHO KNEW OF YOUR RELATIONSHIP:

20.One or more of the employers and/or relatives shown above may be contacted regarding knowledge they may have of your marriage. If you object to our contacting any of the above, please list the name(s) and give the reason(s) for your objection(s).

21. A. DID YOU EVER LIVE WITH ANY OTHER PERSON AS HUSBAND AND WIFE?

Yes

No

B. IF ''YES,'' GIVE THE FOLLOWING INFORMATION:

 

 

 

Dates

Kind of Relationship

Name of Person

How Relationship

Date and Place

(Ceremonial, etc.)

Ended

 

Relationship Ended

 

 

 

Form SSA-754-F4 (02-2016) UF (02-2016)

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(OVER)

22. A. DID THE PERSON NAMED IN ITEM 3 EVER LIVE WITH ANYONE ELSE AS HUSBAND AND WIFE? Yes

No

 

B. IF "YES," GIVE THE FOLLOWING INFORMATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates

Kind of Relationship

Name of Person

How Relationship

Date and Place

 

 

 

(Ceremonial, etc.)

Ended

Relationship Ended

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANSWER ITEM 23 IF EITHER OF YOU HAD AN EARLIER CEREMONIAL OR COMMON-LAW MARRIAGE THAT WAS STILL IN EFFECT AT THE TIME YOU BEGAN LIVING TOGETHER.

23. A. DID YOU AT THE TIME YOU BEGAN LIVING TOGETHER KNOW THAT THE EARLIER

Yes

No

MARRIAGE WAS STILL IN EFFECT?

 

 

IF "NO," ANSWER (B) AND (C):

 

 

B. WHEN AND HOW DID YOU FIND OUT THAT THIS MARRIAGE WAS STILL IN EFFECT?

C. WHEN AND HOW DID THE PERSON WITH WHOM YOU WERE LIVING FIRST LEARN THAT THIS MARRIAGE WAS STILL IN EFFECT?

ANSWER ITEM 24 ONLY IF EITHER OF YOU HAD AN EARLIER CEREMONIAL OR COMMON-LAW MARRIAGE THAT ENDED AFTER YOU BEGAN LIVING TOGETHER.

24.A. WHEN AND HOW DID YOU FIRST LEARN THAT THIS MARRIAGE HAD ENDED?

B.WHEN AND HOW DID THE PERSON WITH WHOM YOU WERE LIVING FIRST LEARN THAT THIS MARRIAGE HAD ENDED?

C.AFTER BOTH OF YOU LEARNED THAT THE EARLIER MARRIAGE HAD ENDED,

DID YOU SAY ANYTHING TO EACH OTHER ABOUT YOUR RELATIONSHIP? Yes No

IF "YES," WHAT DID YOU SAY TO EACH OTHER?

25. REMARKS:

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 30 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL

SECURITY OFFICE. The office is 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.

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 (First name, middle initial, last name)

MAILING ADDRESS (Number and Street, Apt. No., P.O. Box or Rural Route)

County (if any in which you now live)

State

 

 

DATE (Month, day, year)

TELEPHONE NUMBER(S) at which you may be called during the day.

AREA CODE

City

Zip Code

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.

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-754-F4 (02-2016) UF (02-2016)

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1. For starters, while completing the ssa 754, begin with the part with the following blanks:

The best way to complete security form marriage step 1

2. After filling out this part, head on to the subsequent part and fill in the necessary particulars in all these blanks - A If it was in writing furnish a, B WAS THIS UNDERSTANDING LATER, Yes, If yes what were the changes and, DID YOU HAVE AN UNDERSTANDING AS, Yes, If yes what did you say to each, Form SSAF UF Destroy Prior, Page, and OVER.

Completing section 2 of security form marriage

3. Completing A DID YOU HAVE ANY UNDERSTANDING, Yes, B IF YES WHAT DID YOU SAY TO EACH, A DID YOU BELIEVE THAT YOUR, Yes, B IF YES WHY DID YOU BELIEVE SO, A WAS THERE AN AGREEMENT OR, Yes, ALSO BE PERFORMED IN THE FUTURE, B IF YES EXPLAIN WHY THE CEREMONY, A WERE ANY CHILDREN BORN OF THIS, Yes, B IF YES LIST BELOW, FULL NAME AT BIRTH, and DATE OF BIRTH OR AGE is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

security form marriage writing process detailed (part 3)

4. It's time to fill out this next section! Here you've got all these BY WHAT NAMES WERE YOU AND THE, A BEFORE YOU LIVED TOGETHER MANS, B BEFORE YOU LIVED TOGETHER WOMANS, C SINCE YOU LIVED TOGETHER MANS, D SINCE YOU LIVED TOGETHER WOMANS, E IF YOU BOTH DID NOT USE THE SAME, THE REASONS, A AFTER YOU STARTED LIVING, EXECUTED INSURANCE POLICIES TAKEN, Yes, B IF YES GIVE THE FOLLOWING, TYPE OF DOCUMENT, DATE MADE OUT, WERE YOU SHOWN AS THE OTHERS, and Yes empty form fields to fill in.

security form marriage completion process detailed (portion 4)

It is possible to make a mistake while filling out the Yes, thus you'll want to look again before you decide to submit it.

5. As a final point, this last segment is what you'll want to complete prior to finalizing the form. The fields at this stage include the following: NAME OF PERSON OR STORE, ADDRESS, DATE OF TRANSACTION, A HOW DID YOU INTRODUCE THE, NEIGHBORS BUSINESS ACQUAINTANCES, B HOW DID THAT PERSON INTRODUCE, ACQUAINTANCES AND OTHERS, Form SSAF UF, and Page.

A HOW DID YOU INTRODUCE THE, DATE OF TRANSACTION, and Page inside security form marriage

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