SSA-754-F4 Current Version

SOCIAL SECURITY AOMINISTRATION

Form Approved
OMB No, 0960·0038

TOE 420

(Do not write in this space)

STATEMENT OF MARITAL RELATIONSHIP (By one of the parties)
All items on this form requiring an answer must be answered or marked

"Unknown.~

I understand that the information given by me will be us&d in connection with an·
application filed for insurance benefits payable under Title II of the Social Security Act, as
amended. based on the eamings of the wage earner or self·employed person nam~d
below.
Thefo!loWfrlg information is given pursuant to the Privacy Act of 1974. The Sodal Security Administration is authorized to
collect information about your mSfltal status under section 216(h) of the Social Security Act, as amended {42 U.s.C.
41EHhll. While completion of this form is voluntary, failure to provide all or part ohhe requested information could prevent
an accurate and timely decision on your claim and could result in the loss of some benefits. The information on this form
may be disclosed by the Social Security Administration to another person or agency for the following purposes: (1 t to assist
the Social Security Administration in establishing the right of beneficiary to Social Security benefits, (2) facilitate statistical
research and audit activities necessary to assure the integrity and improvement of the Social Security programs, and (3) to
comply with laws requiring authorizing the exchange 01 information between the Social Security Administration and another
agency,
SOCIAL SECURITY NUMBER

IPRINT NAME OF WAGE EARNER OR SELF EMPLOYED PERSON

2. PRINT YOUR FULL NAME (First, middle initial, last)
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4. WHEN DID YOU BEGIN LIVING TOGETHER IN A

[ I I I I I

3, NAME OF PERSON WITH WHOM YOU WERE LIVING:
""'''

WHERE DID YOU LIVE?

HUSBAND AND WIFE RELATIONSHIP?

!YEAR

IMONTH

CITY OR TOWN

U

5. A, DID YOU LIVE TOGETHER CONTINUOUSLY SINCE THAT TIME?
If "No,"

glVEI

STATE

YES
DNO
the periods of separation and the reasons why you did nat live together.

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

IDATE~ROM

TO

,I

6,

010 YOU HAVE AN UNDERSTANDING AS TO YOUR RELATIONSHIP

DYES
DNO
WHEN YOU BEGAN LIVING TOGETHER?
A. If it was in writing, furnish a copy: if it was not in writing. what did you say to each other about your Hving toga the r?

B. WAS THIS UNDERSTANDING LATER CHANGED?
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?
If ~yes," what did you say to each other about how long you would live together?

Form SSA·1S4·F4 Ii 0·2002) EF (05·2004)
Destroy Prior Editions

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YES

NO

DYES

DNO

(0 VERI

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6.

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A. DID YOU HAVE ANY UNDERSTANDING AS TO HOW YOUR RELATIONSHIP COULD BE ENDED?
~YES," WHAT DID VOU SAY TO EACH OTHER ON THIS SUBJECT?

U

--$

YES

0

NO

B. IF

9. A. DID YOU BEUEVE THAT YOUR liVING TOGETHER MADE YOU LEGALLY MARRIED?

DVES

ONO

DYES

DNO

DYES

DNO

S, IF »YES," WHY DID YOU BEUeVE SO?

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

l------------~

..--_l_------"m"".mm.---...- . ­

".._._ _ _ _ _ _._ _ __

12. BY WHAT NAMES WERe VOU AND THE PERSON WITH WHOM YOU WERE LIVING KNOWN?
RE VOU LIVED TOGETHER IMAN'S NAME)
B. BEFORE YOU LIVED TOGETHER (WOMAN'S NAMEJ
l-::-~~::::-:-~----=:___...,___--"-".....,__,_".....,--,.",......---.........f---------...-,,..-

iC. SINCE YOU LIVED TOGETHER lMAN'S NAMEI
E., IF YOU BOTH 010 NOT USE THE

--------­
D. SINCE YOU LIVED TOGETHER (WOMAN'S NAMEl

SAME LAST NAME AFTER YOU BEGAN LIVING TOGETHER,

STATE THE'~REASONS~

13. A. AFTER VOU STARTED LIVING TOGETHER. WERE THERE ANV TAX RETURNS FILED,
DEEDS OR CONTRACTS EXECUTED, INSURANCE POUCIES TAKEN OUT, BANK

ACCOUNTS OPENED UP, ETC?

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

DYES

NO

DVES

NO

1---. TYPE OF DOCUMENT

----------+-----------------t---­

NO

DYES
_~"N"'

__

•••m"." •••• _

'~~

"."

.., , " " ­

NO

DVES

_--+_____________---'1-..._ _ _ _ _ _ _ _, .._._ _ _ _--'-_ _ _ _ _ _ _ _ _ __

"---~

14. A. DID VOU HAVE JOINT BUSINESS DEALINGS WITH OTHER PERSONS OR JOINT
CHARGE ACCOUNTS IN STORE.S?
B. IF "VES," GIVE THE NAMES AND ADDRESSES OF SUCH PERSONS OR STORES;
l---:C"N:-A""'M"":E:-O~F-::-P-::-ER::"S:-O:-N:--C'-=O-=R-S::-:T::-:O:-R=-=E-:---'­
.~.---' ADDRESS

DVES

NO

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

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

, •. !HOW WAS MAIL ADDRESSED TO YOU?
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17. lUST BELOW THE NAMES OF YOUR AND THE OTHER PERSON'S EMPLOYERS AND NEIGHBORS WHO KNEW OF
lYOUR RELATIONSHIP:
I

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.....,'''''''''''''","""",,,

_.,

18,

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

..

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NAME

~~~

RELATIONSHIP

~~~

..

,

19.

LIST BELOW THE CLOSEST RELATIVES OF THE PERSON WITH WHOM YOU WERE liVING lother than childrenl
WHO KNEW OF YOUR RELATIONSHIP:
I

.,

,~

.. .......

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"',"""''''

--,

,

.

­

20.

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

21.

A. DID YOU EVER LIVE WITH ANY OTHER PERSON AS HU~BAND AND WIFE?

I

Itt

DVES

UNO

IF "YES," GIVE THE FOLLOWING INfORMATION:

Oates

Kind of Relationship
(Ceremoniat etc.1

Name of Person

How Relationship

Ended

DatE! ,f.;lA.W MARRIAGE THAT ~DE:O
AFTEAYOU
LWtNG TOGETHER.
24. A. WHEN AND HOW DID YOU FIAST LEARN THAT THIS MARRIAGE HAD ENDED?

A:J. ­

!

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?
IF ~YES.· WHAT DID YOU SAY TO EACH OTHER?

NO

DYES

25. REMARKS:

Papvwol'l RedJlctwlI Act Stlllen_ - 1111., l1!formalioll.l:lJl/ecritJlI nW!tf Ill" r,1quireflumt of"" U,S C. §J507 a.,afflttJldeJ by ,wc:lion 2 of the ~r!f9t.:k&!fl«r:ljW1 Aft f)(

.I!l'l$, You do IWI need to answer these que.f(itmS Ur!lItXN ~ dUpll~" a valid OffiCI! q{""4:magemem ,mdBudgeJ control numbel'. Ue f!cSlima(e Jlwr if wiJI rake abuiJt 15mlmttt:s
If) 7f!ad the fnstrucllUfIlI, gather fJJeJlU:ls, ami an.f1W!r the questions, SEND OR BRING THE COMPIJ~TED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
TIu! oJJke Is lind1UfJkr Us. GtWUlflfU!JfliJltJlfcia III J'D'II' tekpllone Ilinctl11')' Dr you may call Social Security III J-tl0fJ.7'lJ..J111. You IIU{l' send CC_nlJ ()Jl oor Iitmt
e.stimal£ abcw 10, S$A.,!$4'J I S/lcwlly lJ/wl, BaJIU1I()rfI, MD Jl1Jj.Q4Q/, Send!Sli. CfJniImm1s rd4ting 10 t1Ilr timtr ~ to tIIU atldrm. 1fIlI the CDlrfPb!redflmn.

I declare under penalty of perjury that t have examined all the information on this form, and on any accompanying statsmenta or
forms, and it Is true and correct to the be$t of my knowledge. t understand that anyone who knowingly gives a false or
misleading statement about a material filet In this information, Of causes someone else to do so, commits a crime and may be
sent to pflson, or may face other penalties, or both.
'''''''''....''''..
""-SIGNATURE OF APPLICANT (First name. middle initial, last name)
DATE (Month, day, yesr)
SIGN
HERE

.

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TELEPHONE NUMBERIS) at which you may be
called during the day.
---"""""""

MAILING ADDRESS (Number and Street, Apt. N()., P.O. Box or Rural Route)

AREACOOE
"""'-«<-"...,

""""""',...~"-"

City
County (if any in which you now livel

IState

,--""--~~-.-

Zip Code
···········~w~

___

~_··

Witnesses are required only lfthis appllcation has been signed by mark IX! ahove, If Signed by mark (Xl, two wItnesses to the sf9nmg who
know the applicant must sign below, giving tile;' full addresses.
1.

SIGNATURE OF WITNESS

SIGNATURE OF WITNESS

ADDRESS (Number lind Street, City. State, and lJ? Code I

ADDRESS (Number and Street, Cit.,., Stale. and ZIP Codel

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