Form SSA-10 Application for Widow's or Widower's Insurance Benefits

What Is Form SSA-10?

Form SSA-10, Application for Widow's or Widower's Insurance Benefits is a form used by the surviving spouse of an insured wage earner to claim for insurance benefits on the wage earner's file. Use this form to request all insurance benefits you may be eligible for according to Title II: Federal Old-Age, Survivors, and Disability Insurance and Title XVIII, Part A: Health Insurance for the Aged and Disabled.

Form SSA-10 - also known as the SSA Form 10 - was issued by the Social Security Administration (SSA). The latest version of the form was released in June 2017 with previous editions obsolete and an SSA-10 fillable form available for download and digital filing below.

The document has two related forms:

  1. Form SSA-10-INST, Reporting Responsibilities for Widow's or Widower's Insurance Benefits is used to inform recipients of widow's or widower's insurance benefits about their reporting responsibilities, changes they are obliged to report, and the most convenient ways to report them;
  2. Form SSA-4111, Certification of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits is a form you need to complete if you want to receive reduced widow's, widower's, or surviving divorced spouse's benefits. You can claim these benefits if you are not less than 62 years old and under full retirement age.
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SOCIAL SECURITY ADMINISTRATION
Page 1 of 8
Form SSA-10 (06-2017) UF
Form Approved
Destroy Prior Editions
TEL
TOE 120/145/155
OMB No. 0960-0004
APPLICATION FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS*
(Do not write in this space)
With this application, you are applying for all insurance benefits for which you are 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.?If you were receiving spouse's benefits at the time of your spouse's
death, you only need to complete the circled items. All other claimants must complete the entire
form.?*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).
1. (a) PRINT name of deceased wage earner or
FIRST NAME, MIDDLE INITIAL, LAST NAME
self-employed person (herein referred to as
the "deceased")
(b) Check (X) one for the deceased
Male
Female
(c) Enter deceased's Social Security Number
FIRST NAME, MIDDLE INITIAL, LAST NAME
2. (a) PRINT your name
(b) Enter your Social Security Number
FIRST NAME, MIDDLE INITIAL, LAST NAME
(c) Enter your name at birth if different
from item 2(a)
PART I - INFORMATION ABOUT THE DECEASED
3. Enter date of birth of deceased
MONTH, DAY, YEAR
4. (a) Enter date of death
MONTH, DAY, YEAR
(b) Enter place of death
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.
6. (a) Did the deceased ever file an application for Social Security
Yes
No
benefits, a period of disability under Social Security, supplemental
(If "Yes," answer
(If "No," go
security income, or hospital or medical insurance under Medicare?
(b) and (c).)
on to item 7.)
If unknown, check this box
(b) Enter name(s) of person(s) on whose
FIRST NAME, MIDDLE INITIAL, LAST NAME
Social Security record(s) other application
was filed.
(c) Enter Social Security Number(s) of person(s) named in (b).
If unknown, check this box
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.
Yes
No
7. (a) Was the deceased unable to work because of illnesses, injuries
(If "No," go on
(If "Yes," answer (b).)
or conditions at the time of death?
to item 8.)
(b) Enter the date the deceased became unable to work.
MONTH,DAY,YEAR
Yes
No
8. (a) Was the deceased in the active military or naval service
(including Reserve or National Guard active duty or active duty
(If "Yes," answer
(If "No," go on
for training) after September 7, 1939 and before 1968?
(b) and (c).)
to item 9.)
(Month, year)
(Month, year)
(b) Enter dates of service.
FROM:
TO:
(c) Has anyone (including the deceased) received, or does anyone
Yes
No
expect to receive, a benefit from any other Federal agency?
SOCIAL SECURITY ADMINISTRATION
Page 1 of 8
Form SSA-10 (06-2017) UF
Form Approved
Destroy Prior Editions
TEL
TOE 120/145/155
OMB No. 0960-0004
APPLICATION FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS*
(Do not write in this space)
With this application, you are applying for all insurance benefits for which you are 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.?If you were receiving spouse's benefits at the time of your spouse's
death, you only need to complete the circled items. All other claimants must complete the entire
form.?*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).
1. (a) PRINT name of deceased wage earner or
FIRST NAME, MIDDLE INITIAL, LAST NAME
self-employed person (herein referred to as
the "deceased")
(b) Check (X) one for the deceased
Male
Female
(c) Enter deceased's Social Security Number
FIRST NAME, MIDDLE INITIAL, LAST NAME
2. (a) PRINT your name
(b) Enter your Social Security Number
FIRST NAME, MIDDLE INITIAL, LAST NAME
(c) Enter your name at birth if different
from item 2(a)
PART I - INFORMATION ABOUT THE DECEASED
3. Enter date of birth of deceased
MONTH, DAY, YEAR
4. (a) Enter date of death
MONTH, DAY, YEAR
(b) Enter place of death
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.
6. (a) Did the deceased ever file an application for Social Security
Yes
No
benefits, a period of disability under Social Security, supplemental
(If "Yes," answer
(If "No," go
security income, or hospital or medical insurance under Medicare?
(b) and (c).)
on to item 7.)
If unknown, check this box
(b) Enter name(s) of person(s) on whose
FIRST NAME, MIDDLE INITIAL, LAST NAME
Social Security record(s) other application
was filed.
(c) Enter Social Security Number(s) of person(s) named in (b).
If unknown, check this box
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.
Yes
No
7. (a) Was the deceased unable to work because of illnesses, injuries
(If "No," go on
(If "Yes," answer (b).)
or conditions at the time of death?
to item 8.)
(b) Enter the date the deceased became unable to work.
MONTH,DAY,YEAR
Yes
No
8. (a) Was the deceased in the active military or naval service
(including Reserve or National Guard active duty or active duty
(If "Yes," answer
(If "No," go on
for training) after September 7, 1939 and before 1968?
(b) and (c).)
to item 9.)
(Month, year)
(Month, year)
(b) Enter dates of service.
FROM:
TO:
(c) Has anyone (including the deceased) received, or does anyone
Yes
No
expect to receive, a benefit from any other Federal agency?
Form SSA-10 (06-2017) UF
Page 2 of 8
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?
$
Amount
(b) About how much did the deceased earn the year before death?
$
10. (a) Did the deceased have wages or self-employment income
Yes
No
covered under Social Security in all years from 1978 through
(If "Yes," skip to
(If "No,"
last year?
item 11.)
answer (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.
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 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".)
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)
(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)
Where (Name of City and State)
How Marriage Ended
When (Month, Day, and Year)
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 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
(If "Yes," enter the name
at the time of death or at the time the deceased became disabled under
Yes
and address in"Remarks.")
Social Security Law?
PART II - INFORMATION ABOUT YOURSELF
14. (a) Enter name of State or foreign country where you were born.
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 age 5?
Yes
No
Unknown
(c) Was a religious record of your birth made before age 5?
Yes
No
Unknown
Form SSA-10 (06-2017) UF
Page 3 of 8
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)
Spouse's date of birth (or age) If spouse deceased, give date
Marriage performed by
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 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)
Spouse's date of birth (or age) If spouse deceased, give date
Marriage performed by
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 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)
Where (Name of City and State)
How Marriage Ended
When (Month, Day, and Year)
Spouse's date of birth (or age) If spouse deceased, give date
Marriage performed by
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 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
(If "Yes," skip to
No(If "No,"
Yes
No
same address when the deceased died?
item 17.)
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?
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
(If "Yes," skip to
(If "No,"
Yes
No
an application for Social Security benefits, a period of
item 17.)
answer (b).)
disability under Social Security, Supplemental Security
Income, or hospital or medical insurance under Medicare?
(b) Enter name of person on whose Social Security record you
filed other application.
(c) Enter Social Security Number of person named in (b). (if
unknown, so indicate)
Form SSA-10 (06-2017) UF
Page 4 of 8
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,
(If "Yes," answer
(If "No," go on
Yes
No
unable to work because of illnesses, injuries or conditions?
(b) .)
to item 19.)
(b) Enter the date you became unable to work.
(Month, day, year)
19. Were you in the active military or naval service (including
Reserve or National Guard active duty or active duty for
Yes
No
training) after September 7, 1939 and before 1968?
20. Did you or the deceased work in the railroad industry for 5
Yes
No
years or more?
21. (a) Did you or the deceased have Social Security credits
(If "Yes," answer
(If "No," go on
Yes
(for example, based on work or residence) under another
No
(b).)
to item 22.)
country's Social Security System?
(b) If "Yes," list the country(ies)
22. (a) Have you qualified for, or do you expect to qualify
for, a pension or annuity (or a lump sum in place of a pension
(If "Yes," check
or annuity) based on your own employment and earnings for the
which of the items
(If "No," go on
Yes
No
Federal Government of the United States, or one of its States
in item (b) applies
to item 23.)
or local subdivisions that was not covered under Social
to you.)
Security? (Social Security benefits are not
government pensions.)
(b)
I receive a government pension or annuity.
I have not applied for but I expect to begin
receiving my pension or annuity:
I received a lump sum in place of a
government pension or annuity.
I applied for and am awaiting a decision on my
(Month, day, 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
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 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. 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.
23.Do you want to enroll in the Medicare Part B (Medical Insurance)?
Yes
No
Form SSA-10 (06-2017) UF
Page 5 of 8
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 you did
NONE
ALL
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."
Jan.
Feb.
Mar.
Apr.
If all months were exempt months, place an "X" in "ALL."
May
Jun.
Jul.
Aug.
*Enter the appropriate monthly limit after reading the information,
Sept.
Oct.
Nov.
Dec.
"How Work Affects Your Benefits."
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 you did
not or will not earn more than *$
in wages, and did not or will
NONE
ALL
not perform substantial services in self-employment. These months are
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
Jan.
Feb.
Mar.
Apr.
"X" in "ALL."
May
Jun.
Jul.
Aug.
*Enter the appropriate monthly limit after reading the information, "How Work
Sept.
Oct.
Nov.
Dec.
Affects Your Benefits."
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 you do
not expect to earn more than *$
in wages, and do not expect
NONE
ALL
to perform substantial services in self-employment. These months will be
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
Jan.
Feb.
Mar.
Apr.
an "X" in "ALL."
May
Jun.
Jul.
Aug.
*Enter the appropriate monthly limit after reading the
Sept.
Oct.
Nov.
Dec.
information, "How Work Affects Your Benefits."
Month
27. 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.
IF YOU ARE FULL RETIREMENT AGE OR OLDER, GO ON TO ITEM 29. 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.
(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.
(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.
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 benefits on your own earnings record?
Yes
No

Download Form SSA-10 Application for Widow's or Widower's Insurance Benefits

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Form SSA-10 Instructions

The general instructions for completing the SSA Form 10 are provided in the form. Find the detailed step-by-step filling out instructions below. Complete only the circled items if you were receiving the spouse's benefits at the time of your spouse's death. Otherwise, fill out the entire form.

Fill out the form as follows:

  1. Item 1 and 2 are self-explanatory;
  2. Part I. Information about the Deceased. Enter detailed information about your deceased spouse, including dates of birth and death, place of death, place of permanent residence, applications for Social Security benefits, ability to work, active military or naval services (if applicable), and income;
  3. Information about the Deceased's Marriages. Fill out this part only if the deceased spouse had any other marriages;
  4. Item 12A. Complete it if the deceased spouse married someone after the marriage to you. If this is the case, provide the details on the last marriage;
  5. Item 12B. Complete it to provide details on any other marriage that lasted 10 years minimum or ended because of the death of the spouse. If you need more space, use the "Remarks" section;
  6. Item 13. Specify if there are surviving parents who were receiving support from your deceased spouse at the time of death. If yes, specify the address in the "Remarks" section;
  7. Part II. Information about Yourself. Most items of this part are self-explanatory. They require information about the place you were born, record of your birth, information about all of your marriages (including marriage to the deceased, your previous and subsequent marriages), information whether you lived with the deceased at the time of death, your applications for Social Security benefits, your ability to work, and other details;
  8. Item 23. If you are within 3 months of 65 years old or older, you may choose to enroll in the Medical Insurance;
  9. Items 24 - 27. Provide details about your earnings;
  10. Item 28. Complete it only if you are not of full retirement age yet;
  11. Item 29. If you are at least 61 years and 8 months, you may choose this application to be considered as an application for retirement benefits on your own record;
  12. Remarks. Enter here any additional explanations or information;
  13. Specify the details of your direct deposit payment address;
  14. Sign the document, indicate the date, phone number, and full mailing address.

Where to Mail Form SSA-10?

Mail the completed Form SSA-10 to your local Social Security office. Find the address of the nearest office on the SSA website or by calling the national toll-free number provided on page 4 of the form.

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