Current SSA-754-F4

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0038
(Do not write in this space)

TOE 420

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 used in connection with an application filed for
insurance benefits payable under Title II of the Social Security Act, as amended, based on the
earnings of the wage earner or self-employed person named below.
Privacy Act Notice: Section 216(h), of the Social Security Act, as amended, authorizes us to collect this information. We will use this
information to make a determination on your claim. Furnishing us this information is voluntary. However, failure to provide all or part of the
information could prevent us from making an accurate and timely decision on your benefit eligibility. We rarely use the information you
supply for any purpose other than for making a determination relating to benefit eligibility. 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,
audit, or investigative 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. A complete list of routine uses for this information is available in
Systems of Records Notices entitled, Claims Folder Record, 60-0089 and Master Beneficiary Record, 60-0090. These notices, additional
information regarding this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at
your local Social Security office.

1. PRINT NAME OF WAGE EARNER OR SELF EMPLOYED PERSON

SOCIAL SECURITY NUMBER

2. PRINT YOUR FULL NAME (First, middle initial, last)

3. NAME OF PERSON WITH WHOM YOU WERE LIVING:

4. WHEN DID YOU BEGIN LIVING TOGETHER IN A
HUSBAND AND WIFE RELATIONSHIP?

WHERE DID YOU LIVE?

MONTH

YEAR

CITY OR TOWN

STATE

5. A. DID YOU LIVE TOGETHER CONTINUOUSLY SINCE THAT TIME?
YES
If "No," give the periods of separation and the reasons why you did not live together.

NO

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

STATE

DATES
FROM

TO

6. DID YOU HAVE AN UNDERSTANDING AS TO YOUR RELATIONSHIP
YES
NO
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 living together?

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-754-F4 (06-2012) EF (06-2012)
Destroy Prior Editions

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YES

NO

YES

NO

(OVER)

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

YES

NO

9. A. DID YOU BELIEVE THAT YOUR LIVING TOGETHER MADE YOU LEGALLY MARRIED?

YES

NO

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.

YES

NO

11. A. WERE ANY CHILDREN BORN OF THIS RELATIONSHIP?

YES

NO

B. IF "YES," WHY DID YOU BELIEVE SO?

B. IF "YES," LIST BELOW:
FULL NAME AT BIRTH

DATE OF BIRTH (OR AGE)

PLACE OF BIRTH

12. BY WHAT NAMES WERE YOU AND THE PERSON WITH WHOM YOU WERE LIVING KNOWN?
A. BEFORE YOU LIVED TOGETHER (MAN'S NAME)
B. BEFORE YOU LIVED TOGETHER (WOMAN'S NAME)
C. SINCE YOU LIVED TOGETHER (MAN'S NAME)

D. SINCE YOU LIVED TOGETHER (WOMAN'S NAME)

E. IF YOU BOTH DID NOT USE THE SAME LAST NAME AFTER YOU BEGAN LIVING TOGETHER, STATE THE REASONS.
13. A. AFTER YOU STARTED LIVING TOGETHER, WERE THERE ANY TAX RETURNS FILED,
YES
NO
DEEDS OR CONTRACTS EXECUTED, INSURANCE POLICIES TAKEN OUT, BANK
ACCOUNTS OPENED UP, ETC?
B. IF "YES," GIVE THE FOLLOWING INFORMATION:
WERE YOU SHOWN AS THE OTHER'S
HUSBAND/WIFE?
TYPE OF DOCUMENT
DATE MADE OUT

14. A. DID YOU HAVE JOINT BUSINESS DEALINGS WITH OTHER PERSONS OR JOINT
CHARGE ACCOUNTS IN STORES?
B. IF "YES," GIVE THE NAMES AND ADDRESSES OF SUCH PERSONS OR STORES:
NAME OF PERSON OR STORE
ADDRESS

YES

NO

YES

NO

YES

NO

YES

NO

DATE OF TRANSACTION

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

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

16. HOW WAS MAIL ADDRESSED TO YOU?
Form SSA-754-F4 (06-2012) EF (06-2012)

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17.

LIST BELOW THE NAMES OF YOUR AND THE OTHER PERSON'S EMPLOYERS AND NEIGHBORS WHO KNEW OF
YOUR RELATIONSHIP:

18.

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

ADDRESS

RELATIONSHIP

19.

LIST BELOW THE CLOSEST RELATIVES OF THE PERSON WITH WHOM YOU WERE LIVING (other than children)
WHO KNEW OF YOUR RELATIONSHIP:

20.

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

21.

A. DID YOU EVER LIVE WITH ANY OTHER PERSON AS HUSBAND AND WIFE?

YES

NO

B. IF ''YES,'' GIVE THE FOLLOWING INFORMATION:
Dates

Kind of Relationship
(Ceremonial, etc.)

Form SSA-754-F4 (06-2012) EF (06-2012)

Name of Person

Page 3

How Relationship
Ended

Date and Place
Relationship Ended

(OVER)

22. A. DID THE PERSON NAMED IN ITEM 3 EVER LIVE WITH ANYONE ELSE AS
HUSBAND AND WIFE?
B. IF "YES," GIVE THE FOLLOWING INFORMATION:
Dates

Kind of Relationship
(Ceremonial, etc.)

Name of Person

YES

How Relationship
Ended

NO

Date and Place
Relationship Ended

ANSWER ITEM 23 IF EITHER OF YOU HAD AN EARLIER CEREMONIAL OR COMMON-LAW MARRIAGE THAT WAS
STILL IN EFFECT AT THE TIME YOU BEGAN LIVING TOGETHER.
23. A. DID YOU AT THE TIME YOU BEGAN LIVING TOGETHER KNOW THAT THE EARLIER
YES
NO
MARRIAGE WAS STILL IN EFFECT?
IF "NO," ANSWER (B) AND (C):
B. WHEN AND HOW DID YOU FIND OUT THAT THIS MARRIAGE WAS STILL IN EFFECT?
C. WHEN AND HOW DID THE PERSON WITH WHOM YOU WERE LIVING FIRST LEARN THAT THIS MARRIAGE WAS STILL
IN EFFECT?

ANSWER ITEM 24 ONLY IF EITHER OF YOU HAD AN EARLIER CEREMONIAL OR COMMON-LAW MARRIAGE THAT ENDED
AFTER YOU BEGAN LIVING TOGETHER.
24. A. WHEN AND HOW DID YOU FIRST LEARN THAT THIS MARRIAGE HAD ENDED?
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?

YES

NO

25. REMARKS:

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 30 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.
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 APPLICANT (First name, middle initial, last name)
DATE (Month, day, year)
SIGN
HERE

u

TELEPHONE NUMBER(S) at which you may be
called during the day.

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

AREA CODE

City
County (if any in which you now live)

State
Zip Code

Witnesses are required only if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who
know the applicant must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

ADDRESS (Number and Street, City, State, and ZIP Code)

ADDRESS (Number and Street, City, State, and ZIP Code)

Form SSA-754-F4 (06-2012) EF (06-2012)

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