Widow's or Widower's Insurance Benefits Application Form

Amount

(a) Did the deceased have wages or self-employment income covered under

Social Security in all years from 1978 through last year?

(If "Yes," skip

to item 11.)

(If "No,"

answer (b).)

CHECK IF APPLICABLE:

INFORMATION ABOUT THE DECEASED'S MARRIAGE(S)

(a) If the deceased married after his or her marriage to you, enter the information on the last marriage.

(If none, write "NONE".)

Spouse's Name (including maiden name) When (Month, Day, and Year) Where (Name of City and State)

(b) If the deceased had any other marriages, and the marriage lasted at least 10 years or ended due to death of the

spouse (whether before or after you married the deceased), enter the information below. If the deceased divorced

then 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, include the marriage. (If none, write "NONE".)

Spouse's Name (including maiden name) When (Month, Day, and Year) Where (Name of City and State)

How Marriage Ended

When (Month, Day, and Year) Where (Name of City and State)

Spouse's date of birth (or age)

If spouse deceased, give date

of death

(If "Yes," enter the name

and address in "Remarks.")

(a) Enter name of State or foreign country where you were born.

If you have already presented, or if you are now presenting, a public or religious record of your birth established before

you were age 5, go on to item 15.

(b) Was a public record of your birth made before age 5?

(c) Was a religious record of your birth made before age 5?

Marriage performed by:

$

$

Yes No