Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111)

Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0759 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-4111 Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111) Form
Revised PA Statement.pdf Other-Revised PA Statement
SSA-4111 Certificate of Election for Reduced Widow(er)’s and Surv SSA-4111 - Revised.pdf Form
SSA-4111 - Current.pdf SSA-4111 - Current IC Document

Information Collection (IC) Details

IC Title:	Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.335

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4111	Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits	SSA-4111 - Revised.pdf		Yes	No	Fillable Printable
Other-Revised PA Statement			Revised PA Statement.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-4111 - Current	SSA-4111 - Current.pdf	03/12/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.