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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."
Alternate Name:
- SSA Form 10.
Form SSA-10 was released by the U.S. Social Security Administration (SSA) on October 1, 2019 , with previous editions obsolete. An SSA-10 fillable form is available for download and digital filing below.
The document has two related forms, Form SSA-10-INST, Reporting Responsibilities for Widow's or Widower's Insurance Benefits, used to inform recipients of widow's or widower's insurance benefits about their reporting responsibilities , and 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 a reduced widow's, widower's, or surviving divorced spouse's benefits.
Form SSA-10 Instructions
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.
- Item 1 and Item 2 are self-explanatory.
- 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 in Part I ("Information about the Deceased").
- Fill out "Information About the Deceased's Marriages" only if the deceased spouse had any other marriages.
- Complete Item 12A if the deceased spouse married someone after the marriage to you. If this is the case, provide the details on the last marriage.
- Complete Item 12B 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.
- Specify if there are surviving parents who were receiving support from your deceased spouse at the time of death in Item 13. If yes, specify the address in the "Remarks" section.
- Most items of Part II ("Information about Yourself") are self-explanatory. They require information about the place you were born, a 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.
- If you are within 3 months of 65 years old or older, you may choose to enroll in the Medical Insurance (Item 23).
- Provide details about your earnings in Items 24 through 27.
- Complete Item 28 only if you are not of full retirement age yet.
- 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 in Item 29.
- Enter any additional information in "Remarks."
- Specify the details of your direct deposit payment address. 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.
Download Form SSA-10 Application for Widow's or Widower's Insurance Benefits
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