Widow's or Widower's Insurance Benefits Application Form
Form SSA-10 (05-2014) EF (05-2014)
I have not applied for but I expect to begin
receiving my pension or annuity:
I applied for and am awaiting a decision on my
pension or lump sum.
NoYes
Yes No
Yes
Page 4
DO NOT ANSWER QUESTION 18 IF YOU ARE FULL RETIREMENT AGE OR OLDER. GO ON TO QUESTION 19.
(a) Are you, or during the past 14 months have you been, unable to work
because of illnesses, injuries or conditions?
(If "Yes," answer
(b) .)
(If "No," go on to
item 19.)
(Month, day, year)
Were you in the active military or naval service (including Reserve or
National Guard active duty or active duty for training) after September 7,
1939 and before 1968?
Did you or the deceased work in the railroad industry for 5 years
or more?
(a) Did you or the deceased have Social Security credits (for example,
based on work or residence) under another country's Social Security
System?
(If "Yes," answer
(b).)
(If "No," go on to
item 22.)
(b) If "Yes," list the country(ies).
(a) Have you qualified for, or do you expect to qualify for, a pension or
annuity (or a lump sum in place of a pension or annuity) based on
your own employment and earnings for the Federal Government of
the United States, or one of its States or local subdivisions that was
not covered under Social Security? (Social Security benefits are not
government pensions.)
(If "Yes," check
which of the items
in item (b) applies
to you.)
(If "No," go
on to item 23.)
(b)
(Month, year)
(If the date is not known, enter "Unknown".)
MEDICARE INFORMATION
COMPLETE ITEM 23 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 doesn't 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.
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 also can 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
co-payments. 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.
Do you want to enroll in the Medicare Part B (Medical Insurance)?
18.
(b) Enter the date you became unable to work.
19.
20.
21.
22.
23.
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.
NoYes
NoYes
No
I receive a government pension or annuity.
I received a lump sum in place of a government
pension or annuity.
NoYes
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