Widow's or Widower's Insurance Benefits Application Form
Form SSA-10 (05-2014) EF (05-2014)
Dec.Nov.Oct.Sept.
May Jun. Jul. Aug.
Apr.Mar.Feb.Jan.
Dec.Nov.Oct.Sept.
May Jun. Jul. Aug.
Apr.Mar.Feb.Jan.
May
Jan. Feb. Mar. Apr.
Jun. Jul. Aug.
Sept. Oct. Nov. Dec.
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ANSWER ITEM 24 ONLY IF THE DECEASED DIED BEFORE THIS YEAR.
24.
(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."
*Enter the appropriate monthly limit after reading the
information, "How Work Affects Your Benefits."
25.
(a) How much do you expect your total earnings to be this year?
ANSWER ITEM 26 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).
26.
(a) How much do you expect to earn next year?
27.
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
ANSWER QUESTION 29 ONLY IF YOU ARE NOW AT LEAST AGE 61 YEARS, 8 MONTHS.
29.
Do you wish this application to be considered an application for retirement benefits
on your own earnings record?
(Over)
(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."
*Enter the appropriate monthly limit after reading the
information, "How Work Affects Your Benefits."
(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."
*Enter the appropriate monthly limit after reading the
information, "How Work Affects Your Benefits."
IF YOU ARE FULL RETIREMENT AGE OR OLDER, GO ON TO PAGE 6. OTHERWISE, PLEASE READ CAREFULLY
THE INFORMAITON ON PAGE 8 AND ANSWER ONE OF THE FOLLOWING ITEMS.
28.
$
$
$
(a) I want benefits beginning with the earliest possible month.
(b) I am full retirement age (or will be within 4 months) and I want benefits beginning with the earliest possible
month, providing that there is no permanent reduction in my ongoing monthly benefits.
(c) I want benefits beginning with . I understand that either a higher initial payment or a higher
continuing monthly benefit amount may be possible, but I choose not to take it.
NONE ALL
NONE ALL
NONE ALL
NoYes
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