SSA-3 Current Version

Form Approved
OMB No. 0960-0009

TOE 120/420

SOCIAL SECURITY ADMINISTRATION

SEE PAPERWORK/PRIVACY
ACT NOTICE ON REVERSE.
SOCIAL SECURITY NUMBER

MARRIAGE CERTIFICATION
PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

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I am the spouse of the person named below, who has applied for insurance benefits under Title II of the Social Security Act, as
presently amended.
NAME OF SPOUSE (First Name)

(Maiden Name, if applicable)

(Last Name)

1. Indicate whether your present marriage was performed by:
Clergyman or Authorized Public Official

2. Were you married before your present
marriage?

P
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M
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A
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E

P
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M
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Other (Explain)

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Yes

(If ''yes'', give the following information
about each of your previous marriages.)

No

TO WHOM MARRIED

WHEN (Month, Day, Year)

WHERE (City and State)

HOW MARRIAGE ENDED

WHEN (Month, Day, Year)

WHERE (City and State)

MARRIAGE PERFORMED BY:

SPOUSE'S DATE OF BIRTH (or age)

GIVE DATE OF DEATH IF SPOUSE IS
DECEASED

Clergyman or Public Official
Other (Explain in "REMARKS")

Spouse's Social Security Number (If none or unknown, so indicate)

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TO WHOM MARRIED

WHEN (Month, Day, Year)

WHERE (City and State)

HOW MARRIAGE ENDED

WHEN (Month, Day, Year)

WHERE (City and State)

MARRIAGE PERFORMED BY:

SPOUSE'S DATE OF BIRTH (or age)

GIVE DATE OF DEATH IF SPOUSE IS
DECEASED

Clergyman or Public Official
Other (Explain in "REMARKS")

Spouse's Social Security Number (If none or unknown, so indicate)

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u

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REMARKS: (Use this space and the reverse of this form for information about any other previous marriages, if necessary)

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 WAGE EARNER OR SELF-EMPLOYED PERSON
DATE (Month, Day, Year)
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink.)

SIGN
HERE

u

TELEPHONE NUMBER (Area Code)

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

CITY

STATE

ZIP CODE

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the wage earner or self-employed person must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
ADDRESS (Number and Street, City, State and ZIP Code)

Form SSA-3 (11-2009) EF (11-2009) Destroy Prior Editions

2. SIGNATURE OF WITNESS
ADDRESS (Number and Street, City, State and ZIP Code)

Reverse

Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, authorizes us to collect this information. The
information you provide will be used to determine the identity of your spouse.
The information you furnish on this form is voluntary. However, failure to provide the requested
information may prevent us from paying benefits to your spouse.
We rarely use the information you supply for any purpose other than for determining the identity of a
spouse. 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 and audit 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.
Additional information regarding this form, routine uses of information, and our programs and systems,
is available on-line at www.socialsecurity.gov or at your local Social Security office.
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 5 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.

Form SSA-3 (11-2009) EF (11-2009)