OMB control number

Application for Widow's or Widower's Insurance Benefits

OMB 0960-0004 · SSA.

OMB 0960-0004

SSA needs information to make a formal determination for entitlement to widow’s or widower’s benefits. We use Form SSA-10-BK to determine whether an applicant meets the statutory and regulatory conditions for entitlement to widow’s or widower’s under the Old Age, Survivors, and Disability Insurance (OASDI) program. SSA employees interview individuals applying for benefits either face to-face or via telephone and enter the information into the Modernized Claims System (MCS). When MCS is temporary unavailable, technicians use the paper form to record the information. The respondents are applicants for widow’s or widower’s benefits. We are submitting this Change Request to remove requests for pension information as per the Social Security Fairness Act of 2023 (SSFA), which repealed the WEP and Government Pension Offset (GPO) provisions for benefits payable for months after December 2023.

The latest form for Application for Widow's or Widower's Insurance Benefits expires 2026-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-10 Application for Widow's or Widower's Insurance Benefits - Paper Version Form
Justification for a Non-Substantial Change - 0004 (Final).docx Justification for No Material/Nonsubstantive Change
Supporting Statement - 0004 (Final).docx Supporting Statement A
Application for Widow's or Widower's Insurance Benefits - Paper Version Form
Application for Widow's or Widower's Insurance Benefits - Modernized Claims System (MCS) Other-MCS Screens

All Historical Document Collections

202503-0960-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2025-03-14
202202-0960-007 Approved without change	Revision of a currently approved collection	2022-06-01
201810-0960-018 Approved without change	Revision of a currently approved collection	2019-02-26
201612-0960-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-12-16
201512-0960-002 Approved without change	Revision of a currently approved collection	2016-02-24
201409-0960-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-09-09
201211-0960-002 Approved without change	Revision of a currently approved collection	2013-03-11
200909-0960-005 Approved without change	Revision of a currently approved collection	2009-12-08
200805-0960-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2008-05-19
200609-0960-025 Approved with change	Extension without change of a currently approved collection	2006-09-25
200608-0960-018 Approved without change	No material or nonsubstantive change to a currently approved collection	2006-09-01
200310-0960-011 Approved without change	Extension without change of a currently approved collection	2003-10-31
200212-0960-011 Approved without change	Revision of a currently approved collection	2002-12-23
199911-0960-005 Approved without change	Reinstatement with change of a previously approved collection	1999-11-08
199909-0960-008 Approved without change	No material or nonsubstantive change to a currently approved collection	1999-09-23
199608-0960-007 Approved without change	Extension without change of a currently approved collection	1996-08-16
199307-0960-006 Approved without change	Extension without change of a currently approved collection	1993-07-26
199005-0960-006 Approved without change	Revision of a currently approved collection	1990-05-14
198908-0960-010 Approved with change	No material or nonsubstantive change to a currently approved collection	1989-08-25
198706-0960-002 Approved without change	Revision of a currently approved collection	1987-06-23
198409-0960-012 Approved with change	No material or nonsubstantive change to a currently approved collection	1984-09-26
198408-0960-003 Approved without change	Revision of a currently approved collection	1984-08-15
198302-0960-009 Approved without change	Revision of a currently approved collection	1983-02-28
198209-0960-003 Approved without change	Revision of a currently approved collection	1982-09-29
198110-0960-005 Approved without change	Revision of a currently approved collection	1981-10-02
198009-0960-004 Approved without change	Revision of a currently approved collection	1980-09-09
197912-0960-003 Approved without change	Revision of a currently approved collection	1979-12-21
197909-0960-010 Approved with change	No material or nonsubstantive change to a currently approved collection	1979-09-28
197809-0960-015 Approved with change	No material or nonsubstantive change to a currently approved collection	1978-09-28
197807-0960-006 Approved without change	Revision of a currently approved collection	1978-07-26
197804-0960-019 Approved with change	No material or nonsubstantive change to a currently approved collection	1978-04-07
197711-0960-013 Approved with change	No material or nonsubstantive change to a currently approved collection	1977-11-30

OMB Details

Application for Widow's or Widower's Insurance Benefits - Paper Version

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form SSA-10

Application for Social Security Benefits

Fillable Printable

Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.