Certificate of Election for Reduced Widow(er)’s Benefits (SSA-4111)

Facsimile:  CELE - Certificate of Election

COMM                           CERTIFICATE OF ELECTION                CELE

[1-D]                            [2-D]                                [3-D]

NH: SSSSSSSSS SSSSS SSSSSSSSSS   BN: SSSSSSSSS SSSSS SSSSSSSSSS       PIC: SSS

[4-D]                                 [5-D]                   [6-D]

BENE ENT DATE OF FILING: SSSSSSSS     START: SSSSSS           TERM: SSSSSS

 [7-M]

*WHAT IS THE CERTIFICATE OF ELECTION EFFECTIVE MONTH (MMCCYY):  999999

[8-o]

REMARKS: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

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[9-O]