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8Form SSA-2-BK (07-2018) UF
Discontinue Prior Editions
Page 1 of 8
SOCIAL SECURITY ADMINISTRATION
OMB No 0960-0618
(Do not write in this space)
APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS
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.
Supplement. If you have already completed an application entitled "APPLICATION
FOR RETIREMENT INSURANCE BENEFITS", you need complete only the circled
items. All other claimants must complete the entire form.
1.
(a) PRINT Name of Wage Earner or Self-
FIRST NAME, MIDDLE INITIAL, LAST NAME
Employed Person
(Herein referred to as the "Worker")
(b) Enter Worker's Social Security Number
Male
Female
2.
Check (X) whether you are
3.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(a) PRINT your name
(b) Enter your Social Security Number
Answer question 4 if English is not your preferred language. Otherwise go to item 5.
Speak
Write
4.
Enter the language you prefer to:
5.
MONTH, DAY, YEAR
(a) Enter your date of birth
(b) Enter name of city and state, or foreign country where you were born
Yes
No
Unknown
(c) Was a public record of your birth made before you were age 5?
Yes
No
Unknown
(d) Was a religious record of your birth made before you were age 5?
6.
No
Yes
(a) Are you a U.S. citizen?
(If "Yes," go to item 7.)
(If "No," answer (b).)
Yes (Go to item (c))
No (Go to item 7)
(b) Are you an alien lawfully present in U.S.?
(c) When were you lawfully admitted to the U.S.?
FIRST NAME, MIDDLE INITIAL, LAST NAME
7.
(a) Enter your full name at birth if different from
item 3(a)
Yes
No
(b) Have you used any other name(s)?
(If "Yes," answer (c).)
(If "No," go to Item 8.)
(c) Other name(s) used.
8.
(a) Have you used any other Social Security number(s)?
Yes
No
(b) Enter Social Security number(s) used.
Form SSA-2-BK (07-2018) UF
Discontinue Prior Editions
Page 1 of 8
SOCIAL SECURITY ADMINISTRATION
OMB No 0960-0618
(Do not write in this space)
APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS
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.
Supplement. If you have already completed an application entitled "APPLICATION
FOR RETIREMENT INSURANCE BENEFITS", you need complete only the circled
items. All other claimants must complete the entire form.
1.
(a) PRINT Name of Wage Earner or Self-
FIRST NAME, MIDDLE INITIAL, LAST NAME
Employed Person
(Herein referred to as the "Worker")
(b) Enter Worker's Social Security Number
Male
Female
2.
Check (X) whether you are
3.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(a) PRINT your name
(b) Enter your Social Security Number
Answer question 4 if English is not your preferred language. Otherwise go to item 5.
Speak
Write
4.
Enter the language you prefer to:
5.
MONTH, DAY, YEAR
(a) Enter your date of birth
(b) Enter name of city and state, or foreign country where you were born
Yes
No
Unknown
(c) Was a public record of your birth made before you were age 5?
Yes
No
Unknown
(d) Was a religious record of your birth made before you were age 5?
6.
No
Yes
(a) Are you a U.S. citizen?
(If "Yes," go to item 7.)
(If "No," answer (b).)
Yes (Go to item (c))
No (Go to item 7)
(b) Are you an alien lawfully present in U.S.?
(c) When were you lawfully admitted to the U.S.?
FIRST NAME, MIDDLE INITIAL, LAST NAME
7.
(a) Enter your full name at birth if different from
item 3(a)
Yes
No
(b) Have you used any other name(s)?
(If "Yes," answer (c).)
(If "No," go to Item 8.)
(c) Other name(s) used.
8.
(a) Have you used any other Social Security number(s)?
Yes
No
(b) Enter Social Security number(s) used.
Form SSA-2-BK (07-2018) UF
Page 2 of 8
DO NOT ANSWER QUESTION 9 IF YOU ARE ONE YEAR PAST FULL RETIREMENT AGE OR OLDER.
GO ON TO QUESTION 10.
No
9.
Yes
(a) Are you, or during the past 14 months have you been,
(If "Yes," answer(b).)
(If "No," go to item 10.)
unable to work because of illnesses, injuries or conditions?
MONTH, DAY, YEAR
(b) If “Yes” when do you believe your condition(s) became
severe enough to keep you from working (even if you have
never worked)?
10.
(a) Have you (or has someone on your behalf) ever filed an
Yes
No
application for Social Security benefits, a period of disability
(If "Yes," answer (b)
(If "No," go to item 11.)
under Social Security, Supplemental Security Income, or
and (c).)
hospital or medical insurance under Medicare?
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter name of person(s) on whose Social Security
record you filed other application.
(c) Enter Social Security Number(s) of person named in
(b). (If unknown, so indicate)
11.
Yes
No
(a) Were you in the active military or naval service (including
Reserve or National Guard active duty or active duty for
(If "Yes," answer (b)
(If "No," go to item 12.)
training) after September 7, 1939 and before 1968?
and (c).)
(MONTH, YEAR)
(MONTH, YEAR)
(b) Enter date(s) of service
From:
To:
(c) Have you ever been (or will you be) eligible for monthly
Yes
No
benefits from a military or civilian Federal agency (Include
Veterans Administration benefits only if you waived Military
retirement pay)?
12.
Did you, or your spouse, (or prior spouse) work in the railroad
Yes
No
industry for 5 years or more?
13.
(a) Do you have Social Security credits (for example, based on
Yes
No
work or residence) under another country's Social Security
(If "Yes," answer (b).)
(If "No," go to item 14.)
system?
(b) List the other country (ies).
14.
(a) Are you entitled to, or do you expect to be entitled to a
Yes
No
pension or annuity (or a lump sum in place of a pension or
(If "Yes," check which
(If "No," go on to
annuity) based on your own employment and earnings from
the Federal government of the United States, or one of its
of the items in item (b)
item 15.)
States or local subdivisions? (Social Security benefits are not
applies to you.)
government pensions.)
(b) Check one box and provide the date in (c)
(c) MONTH
YEAR
I receive a government pension or annuity.
I received a lump sum in place of a government pension or annuity.
(If the date is not known,
I applied for and am awaiting a decision on my pension or lump sum.
enter "Unknown".)
I have not applied for but I expect to begin receiving my pension
or annuity.
I agree to promptly notify the Social Security Administration if I become
entitled to a pension, an annuity, or a lump sum payment based on my
employment not covered by Social Security, or if my pension or annuity
amount changes or stops.
Form SSA-2-BK (07-2018) UF
Page 3 of 8
15.
(a) Enter information about your marriage to the worker. If you married the worker more than once, use the
'Remarks' space to enter the additional marriage information. Go to item 15(b) if you are filing as a divorced
spouse; otherwise, go to item 15(c)
Spouse's name (including maiden name)
When (Month, day, year)
Where (Name of City and State)
How marriage ended (If still in effect,
When (Month, day, year)
Where (Name of City and State)
write "Not Ended.")
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)
(b) If you remarried after the divorce from the worker, enter the marriage information. If you did not remarry, write
"None" Go on to item 15(c) if you had other marriages.
Spouse's name (including maiden name)
When (Month, day, year)
Where (Name of City and State)
How marriage ended
When (Month, day, 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)
(c) Enter information about any marriage if you:
• Had a marriage that lasted at least 10 years; or
• Had a marriage that ended due to the death of your spouse, regardless of duration; or
• Were divorced, 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. Use the "Remarks" space to enter the additional
marriage information. Do not repeat any marriages listed in item 16(a) or 16(b). If none, write "None". _________
To whom married
When (Month, day, year)
Where (Name of City and State)
How marriage ended
When (Month, day, 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)
(Use "Remarks" space on page 5 for information about any other marriages.)
If you are now under full retirement age or less than one year past full retirement age, answer question 16.
If you are more than one year past full retirement age, go to question 17.
Form SSA-2-BK (07-2018) UF
Page 4 of 8
16. Has an unmarried child of the worker (including adopted child, or stepchild) or a
dependent grandchild of the worker (including stepgrandchild) who is under 16 or
Yes
No
disabled lived with you during any of the last 13 months (counting the present month)?
(If "Yes, "enter the information requested below)
Name of child
Months child lived with you (if all, write "All")
17.
Enter below the names and addresses of all the persons, companies, or government agencies for whom you have
worked this year, last year, and the year before last. IF NONE, WRITE "NONE" BELOW AND GO ON TO THE
INSTRUCTIONS FOR ITEM 21.
Work Ended
(If still working,
NAME AND ADDRESS OF EMPLOYER
Work Began
Show "Not
(If you had more than one employer, please list them
Ended")
in order beginning with your last (most recent) employer).
Month
Year
Month
Year
(If you need more space, use "Remarks")
$
(a) How much were your total earnings last year?
18.
(b) Place an "X" in each block for EACH MONTH of last year in which you
NONE
ALL
did not earn more than *$
in wages, and did not perform
substantial services inself-employment. These months are exempt months.
Jan.
Feb.
Mar.
Apr.
If no months were exempt months, place an "X" in "NONE". If all months
were exempt months, place an "X" in "ALL".
May
Jun.
Jul.
Aug.
*Enter the appropriate monthly limit after reading the instructions,
Sept.
Oct.
Nov.
Dec.
"How Work Affects Your Benefits".
$
(a) How much do you expect your total earnings to be this year?
19.
(b) Place an "X" in each block for EACH MONTH of this year in which you
NONE
ALL
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
Jan.
Feb.
Mar.
Apr.
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 "X" in "ALL".
May
Jun.
Jul.
Aug.
*Enter the appropriate monthly limit after reading the instructions,
Sept.
Oct.
Nov.
Dec.
"How Work Affects Your Benefits".
Answer this item 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).
$
(a) How much do you expect to earn next year?
20.
(b) Place an "X" in each block for EACH MONTH of next year in which you
NONE
ALL
do not expect to earn more than *$
in wages, and do not expect
to perform substantial services in self-employment. These months will be
Jan.
Feb.
Mar.
Apr.
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 an
"X" in "ALL".
May
Jun.
Jul.
Aug.
*Enter the appropriate monthly limit after reading the instructions,
Sept.
Oct.
Nov.
Dec.
"How Work Affects Your Benefits".
If you use a fiscal year, that is, a taxable year that does not end December 31 (with income tax return due April 15),
enter here the month your fiscal year ends.
Month
Form SSA-2-BK (07-2018) UF
Page 5 of 8
If you are now under full retirement age and do not have an entitled child in your care, answer item 21. If you
are full retirement age or older or you have an entitled child in your care, go to item 22.
PLEASE READ CAREFULLY THE INFORMATION ON THE BOTTOM OF PAGE 8 AND ANSWER ONE OF
THE FOLLOWING ITEMS.
21. (a) I want benefits beginning with the earliest possible month and will accept an age related reduction.
(b) I am full retirement age (or will be within 12 months) and want benefits beginning with the earliest
possible month providing there is no permanent reduction in my ongoing monthly benefits.
(c) I want benefits beginning with
.
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 22 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 does not 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.
Late Enrollment Penalty
If you do not sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as
you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have
had Part B, but did not sign up for it. Also, you may have to wait until the General Enrollment Period (January 1 to
March 31) to enroll in Part B, and coverage will start July 1 of that year.
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 can also 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.
Yes
No
22.
Do you want to enroll in Medicare Part B (Medical Insurance)?
If you are within 2 months of age 65 or older, blind or disabled,
23.
Yes
No
do you want to file for Supplemental Security Income?
REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)
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