Current Version of the SSA-2

Form SSA-2-BK (06-2022) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 8
OMB No 0960-0618
(Do not write in this space)

APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS
I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age,
Survivors, and Disability Insurance) and Part A of Title XVIII (Health Insurance for the Aged
and Disabled) of the Social Security Act, as presently amended.
Supplement. If you have already completed an application entitled "APPLICATION FOR
RETIREMENT INSURANCE BENEFITS", you need complete only the circled items. All
other claimants must complete the entire form.
1. (a) PRINT Name of Wage Earner or SelfEmployed Person
(Herein referred to as the "Worker")

FIRST NAME, MIDDLE INITIAL, LAST NAME

(b) Enter Worker's Social Security Number
2. Check (X) whether you are

Male

3.

Female

FIRST NAME, MIDDLE INITIAL, LAST NAME
(a) PRINT your name
(b) Enter your Social Security Number
Answer question 4 if English is not your preferred language. Otherwise go to item 5.

4. Enter the language you prefer to:

Write

Speak

5.

Month, Day, Year
(a) Enter your date of birth
(b) Enter name of city and state, or foreign country where you were born

6.
(a) Are you a U.S. citizen?

Yes
(If "Yes," go to item 7.)

No
(If "No," answer (b).)

(b) Are you an alien lawfully present in U.S.?

Yes
(If "Yes," go to item (c).)

No
(If "No," go to item 7.)

(c) When were you lawfully admitted to the U.S.?
7.

(a) Enter your full name at birth if different from
item 3(a)
(b) Have you used any other name(s)?

FIRST NAME, MIDDLE INITIAL, LAST NAME

Yes
(If "Yes," answer (c).)

No
(If "No," go to Item 8.)

(c) Other name(s) used.

8.

(a) Have you used any other Social Security
number(s)?
(b) Enter Social Security number(s) used.

Yes

No

Form SSA-2-BK (06-2022) UF

Page 2 of 8

DO NOT ANSWER QUESTION 9 IF YOU ARE ONE YEAR PAST FULL RETIREMENT AGE OR OLDER.
GO ON TO QUESTION 10.
9.

(a) Are you, or during the past 14 months have you been, unable
to work because of illnesses, injuries or conditions?
(b) If “Yes” when do you believe your condition(s) became severe
enough to keep you from working (even if you have never
worked)?

Yes
(If "Yes," answer(b).)

No
(If "No," go to item 10.)

Month, Day, Year

10. Did you, or your spouse, (or prior spouse) work in the railroad
industry for 5 years or more?
11. (a) Do you have Social Security credits (for example, based on
work or residence) under another country's Social Security
system?

Yes

No

Yes
(If "Yes," answer (b).)

No
(If "No," go to item 12.)

(b) List the other country(ies).
12. (a) Are you entitled to, or do you expect to be entitled to a pension
or annuity (or a lump sum in place of a pension or annuity)
based on your own employment and earnings from the Federal
government of the United States, or one of its States or local
subdivisions? (Social Security benefits are not government
pensions.)
(b) Check one box and provide the date in (c)

Yes
(If "Yes," check which
of the items in item (b)
applies to you.)

No
(If "No," go on to
item 13.)

I receive a government pension or annuity.
I received a lump sum in place of a government pension or annuity.
I applied for and am awaiting a decision on my pension or lump sum.
I have not applied for but I expect to begin receiving my pension or annuity.
(c) Month and Year (If the date is not known, enter "Unknown".)

I agree to promptly notify the Social Security Administration if I
become entitled to a pension, an annuity, or a lump sum
payment based on my employment not covered by Social
Security, or if my pension or annuity amount changes or stops.
13. (a) Enter information about your marriage to the worker. If you married the worker more than once, use the 'Remarks' space
to enter the additional marriage information. Go to item 13(b) if you are filing as a divorced spouse; otherwise, go to item
13(c).
Spouse's name (including maiden name)
When (Month, Day, Year)
Where (Name of City and State)

How marriage ended (If still in effect, write
"Not Ended.")

When (Month, Day, Year)

Marriage performed by:
Clergyman or public official

Spouse's date of birth (or age)

Other (Explain in "Remarks")
Spouse's Social Security Number (If none or unknown, so indicate)

Where (Name of City and State)

If spouse deceased, give date of death

Form SSA-2-BK (06-2022) UF
Page 3 of 8
13. (b) If you remarried after the divorce from the worker, enter the marriage information. If you did not remarry, write "None" Go
on to item 13(c) if you had other marriages.
Spouse's name (including maiden name)
When (Month, Day, Year)
Where (Name of City and State)

How marriage ended

When (Month, Day, Year)

Marriage performed by:
Clergyman or public official

Spouse's date of birth (or age)

Where (Name of City and State)

If spouse deceased, give date of death

Other (Explain in "Remarks")
Spouse's Social Security Number (If none or unknown, so indicate)
(c) Enter information about any marriage if you:
• Had a marriage that lasted at least 10 years; or
• Had a marriage that ended due to the death of your spouse, regardless of duration; or
• Were divorced, remarried the same individual within the year immediately following the year of the divorce, and the
combined period of marriage totaled 10 years or more. Use the "Remarks" space to enter the additional marriage
information. Do not repeat any marriages listed in item 13(a) or 13(b). If none, write "None".
Where (Name of City and State)
Spouse's name (including maiden name)
When (Month, Day, Year)

How marriage ended

When (Month, Day, Year)

Marriage performed by:
Clergyman or public official

Spouse's date of birth (or age)

Where (Name of City and State)

If spouse deceased, give date of death

Other (Explain in "Remarks")
Spouse's Social Security number (If none or unknown, so indicate)
(Use "Remarks" space on page 5 for information about any other marriages.)
If you are now under full retirement age or less than one year past full retirement age, answer question 14.
If you are more than one year past full retirement age, go to question 15.
14. Has an unmarried child of the worker (including adopted child, or stepchild) or a dependent
grandchild of the worker (including stepgrandchild) who is under 16 or disabled lived with you
during any of the last 13 months (counting the present month)? (If "Yes, "enter the information
requested below)
Name of child

Yes

Months child lived with you (if all, write "All")

No

Form SSA-2-BK (06-2022) UF
Page 4 of 8
15. Enter below the names and addresses of all the persons, companies, or government agencies for whom you have worked
this year, last year, and the year before last. IF NONE, WRITE "NONE" BELOW AND GO ON TO THE INSTRUCTIONS
FOR ITEM 19.
NAME AND ADDRESS OF EMPLOYER
(If you had more than one employer, please list them
in order beginning with your last (most recent) employer).

Work Began
Month

Year

Work Ended
(If still working,
Show "Not
Ended")
Month
Year

(If you need more space, use "Remarks")
16. (a) How much were your total earnings last year?

$

(b) Place an "X" in each block for EACH MONTH of last year in which you did not earn more
than *$
in wages, and did not perform substantial services in self-employment.
These months are exempt months. If no months were exempt months, place an "X" in
"NONE". If all months were exempt months, place an "X" in "ALL".

NONE

*Enter the appropriate monthly limit after reading the instructions, How Work Affects Your
Benefits".
17. (a) How much do you expect your total earnings to be this year?

ALL

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

$

(b) Place an "X" in each block for EACH MONTH of this year in which you did not or will not
earn more than *$
in wages, and did not or will not perform substantial
services in self-employment. These months are exempt months. If no months are or will
be exempt months, place an "X" in "NONE". If all months are or will be exempt months,
place an "X" in "ALL".

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

*Enter the appropriate monthly limit after reading the instructions, "How Work Affects
Your Benefits".

Sept.

Oct.

Nov.

Dec.

NONE

ALL

Answer this item ONLY if you are now in the last 4 months of your taxable year (Sept., Oct., Nov., and Dec., if your
taxable year is a calendar year).
18. (a) How much do you expect to earn next year?
$
(b) Place an "X" in each block for EACH MONTH of next year in which you
do not expect
to earn more than *$
in wages, and do not expect to perform substantial
services in self-employment. These months will be exempt months. If no months are
expected to be exempt months, place an "X" in "NONE". If all months are expected to be
exempt months, place an "X" in "ALL".

NONE

ALL

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

*Enter the appropriate monthly limit after reading the instructions, "How Work Affects
Sept.
Oct.
Nov.
Dec.
Your Benefits".
If you use a fiscal year, that is, a taxable year that does not end December 31 (with income tax return due April 15), enter
here the month your fiscal year ends.
Month

If you are now under full retirement age and do not have an entitled child in your care, answer item 19. If you are full
retirement age or older or you have an entitled child in your care, go to item 20.

Form SSA-2-BK (06-2022) UF

Page 5 of 8

PLEASE READ CAREFULLY THE INFORMATION ON THE BOTTOM OF PAGE 8 AND ANSWER ONE OF
THE FOLLOWING ITEMS.
19.

(a) I want benefits beginning with the earliest possible month and will accept an age related reduction.
(b) I am full retirement age (or will be within 12 months) and want benefits beginning with the earliest
possible month providing there is no permanent reduction in my ongoing monthly benefits.
(c) I want benefits beginning with

.
MEDICARE INFORMATION

If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of age 65 or older you could
automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you
live in Puerto Rico or a foreign country, you are not eligible for automatic enrollment in Medicare Part B, and you will need to
contact Social Security to request enrollment.
COMPLETE ITEM 20 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER
Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other services that
Medicare Part A does not cover, such as some of the services of physical and occupational therapists and some home health
care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be determined
when your coverage begins. In some cases, your premium may be higher based on information about your income we receive
from the Internal Revenue Service. Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or
Office of Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a letter explaining
how to pay your premiums. You will also get a letter if there is any change in the amount of your premium.
If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with
Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles, and prescription copayments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the
nearest Social Security office.
Late Enrollment Penalty
If you do not sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as you have
Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but did not
sign up for it. Also, you may have to wait until the General Enrollment Period (January 1 to March 31) to enroll in Part B, and
coverage will start July 1 of that year.
You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug plans and
when you can enroll, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare can
also tell you about agencies in your area that can help you choose your prescription drug coverage. The amount of your premium
varies based on the prescription drug plan provider. The amount you pay for Part D coverage may be higher than the listed plan
premium, based on information about your income we receive from the Internal Revenue Service.
If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with
Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles, and prescription copayments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the
nearest Social Security office.
20. Do you want to enroll in Medicare Part B (Medical Insurance)?

Yes

No

21. If you are within 2 months of age 65 or older, blind or disabled, do you want to file for
Supplemental Security Income?

Yes

No

REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)
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Form SSA-2-BK (06-2022) UF

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REMARKS (con't.)
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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 face other penalties, or both.
Date (Month, Day, Year)

SIGNATURE OF APPLICANT

Telephone number(s) at which
you may be contacted during
the day

SIGNATURE (First Name, Middle Initial , Last Name) (Write in ink)

Direct Deposit Payment Information (Financial Institution)
Routing Transit Number

Account Number

Checking

Enroll in Direct Express

Savings

Direct Deposit Refused

Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if
different.)
City and State

ZIP Code

County (if any) in which you now live

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses who
know the applicant must sign below, giving their full addresses. Also, print the applicant's name in the Signature block.
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-2-BK (06-2022) UF

Page 7 of 8

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY WIFE'S OR HUSBAND'S INSURANCE BENEFITS
BEFORE YOU RECEIVE
A NOTICE OF AWARD

SSA OFFICE

DATE CLAIM RECEIVED

TELEPHONE NUMBER(S) TO CALL
IF YOU HAVE A QUESTION OR
AFTER YOU RECEIVE A
SOMETHING TO REPORT
NOTICE OF AWARD

Your application for Social Security benefits has been
received and will be processed as quickly as possible.
You should hear from us within
days after you
have given us all the information we requested. Some
claims may take longer if additional information is needed.
In the meantime, if you have a change of address,
CLAIMANT

or if there is some other change that may affect your
claim, you - or someone for you - should report the
change to the telephone number shown above. The
changes to be reported are listed on page 8. Always give
us your claim number when writing or telephoning about
your claim.
If you have any questions about your claim, we will be
glad to help you.

WORKER'S SURNAME IF DIFFERENT SOCIAL SECURITY NUMBER
FROM CLAIMANT'S

Privacy Act Statement
Collection and Use of Information
Sections 202, 205, 223(a), and 226 of the Social Security Act, as amended, allows us to collect this information. Furnishing us
this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision
on the claim for benefits.
We will use the information you provide to establish or determine benefits eligibility. We may also share the information for the
following purposes, called routine uses:
• To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of
our programs; and
• To student volunteers, individuals working under a personal services contract, and other workers who technically do not
have the status of Federal employees, when they are performing work for SSA, as authorized by law, and they need access
to personally identifiable information in SSA records in order perform their assigned agency functions.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0059, entitled Earnings
Recording and Self-Employment Income System, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1819
and 60-0089, entitled Claims Folders System, as published in the FR on October 31, 2019, at 84 FR 58422. Additional
information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.
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 11 minutes to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social
Security office through SSA's website at www.socialsecurity.gov. Offices are also 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-2-BK (06-2022) UF

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Page 8 of 8
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE
MONETARY PENALTIES
You change your mailing address for checks or residence.
Custody Change or Disability Improves - Report if a person
for whom you are filing, or who is in your care dies, leaves
(To avoid delay in receipt of checks you should ALSO file a
your care or custody, changes address, or if disabled, the
regular change of address notice with your post office.)
condition improves.
Your citizenship or immigration status changes.
If you become the parent of a child (including an adopted
Any beneficiary goes outside the U.S.A. for 30 consecutive
child) after you have filed your claim, let us know about the
days or longer.
child so we can decide if the child is eligible for benefits.
Any beneficiary dies or becomes unable to handle benefits
Failure to report the existence of these children may result in
the loss of possible benefits to the child(ren).
Work Changes - On your application you told us you expect
total earnings for
to be $
.
Your stepchild is entitled to benefits on your record and you
and the stepchild's parent divorce. Stepchild benefits are not
(Year)
payable beginning with the month after the month the divorce
You
(are)
(are not) earning wages of more than
becomes final.
$
a month
HOW TO REPORT
You
(are)
(are not) self-employed rendering
You can make your reports online, by telephone, mail, or in
substantial services in your trade or business.
person, whichever you prefer.
(Report AT ONCE if this work pattern changes)
If you are awarded benefits, and one or more of the above
change(s) occur, you should report by:
Change of Marital Status - Marriage, divorce, and annulment
• Visiting the section “my Social Security” at our web site at
of marriage. You must report marriage even if you believe
www.socialsecurity.gov;
that an exception applies.
• Calling us TOLL FREE at 1-800-772-1213;
You are confined to a jail, prison, penal institution or
• If you are deaf or hearing impaired, calling us TOLL FREE
correctional facility for more than 30 continuous days for
at TTY 1-800-325-0778; or
conviction of a crime, or you are confined for more than 30
• Calling, visiting or writing your local Social Security office at
continuous days to a public institution by a court order in
the phone number and address shown on
your claim
connection with a crime.
receipt.
You have an unsatisfied warrant for more than 30 continuous
For general information about Social Security, visit our web
days for your arrest for a crime or attempted crime that is a
site at www.socialsecurity.gov.
felony of flight to avoid prosecution or confinement, escape
For
those under full retirement age, the law requires that a
from custody and flight-escape. In most jurisdictions that do
report
of earnings be filed with SSA within 3 months and 15
not classify crimes as felonies, this applies to a crime that is
days
after
the end of any taxable year in which you earn more
punishable by death or imprisonment for a term exceeding
than
the
annual
exempt amount. You may contact SSA to file
one year (regardless of the actual sentence imposed).
a report. Otherwise, SSA will use the earnings reported by
your employer(s) and your self-employment tax return (if
You have an unsatisfied warrant for more than 30 continuous
applicable) as the report of earnings required by law and
days for a violation of probation or parole under Federal or
adjust benefits under the earnings test. It is your responsibility
State law.
to ensure that the information you give concerning your
You become entitled to a pension, an annuity, or a lump sum
earnings is correct. You must furnish additional information as
payment based on your employment not covered by Social
needed when your benefit adjustment is not correct based on
Security, or if such pension or annuity stops.
the earnings on your record.

•
•
•

Under a special rule known as the Monthly Earnings Test, you can get a full benefit for any month in which you do not
earn wages over the monthly limit and do not perform substantial services in self-employment regardless of how much
you earn in the year. For retirement age beneficiaries this special rule can be used only for one taxable year which will
usually be the year of retirement. For younger beneficiaries such as young wives and husbands (entitled only by reason
of child-in-care), this special rule can be used for two taxable years. The first taxable year in which the monthly earnings
test may be used is usually the first year they are entitled to benefits. The second taxable year in which the monthly
earnings test can be used is always the year in which their entitlement to benefits stops. In all other years, the total
amount of benefits payable will be based solely on your total yearly earnings without regard to monthly earnings or
services rendered in self-employment.
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE YOU ANSWER QUESTION 19.

you are under full retirement age, wife's or husband's benefits cannot be paid for any month before the month in which you file
• Ifyour
claim.
retirement age or older, wife's or husband's benefits may be payable for some months before the month in which
• Ifyouyoufilearethisfullclaim,
but not before the month you attain full retirement age.
your first month of entitlement is prior to full retirement age, your benefit rate will be reduced. However, if you do not actually
• Ifreceive
your full benefit amount for one or more months before full retirement age because benefits are withheld due to your
earnings, your benefit will be increased at full retirement age to give credit for this withholding. Thus, your benefit amount at full
retirement age will be reduced only if you receive one or more full benefit payments prior to the month you attain full retirement
age.