OMB control number

Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits

OMB 0960-0759 · SSA.

OMB 0960-0759

To elect reduced widow(er) benefits, a recipient completes Form SSA-4111, and mails it back to SSA. SSA uses the information to pay a qualified dually entitled widow(er) (or surviving divorced spouse) who elects to receive a reduced widow(er) benefit. The respondents are qualified dually entitled widow(er)s (or surviving divorced spouse) who elect to receive a reduced widow(er) benefit.

The latest form for Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits expires 2026-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-4111 Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111) Form
Supporting Statement - 0759 (Final).docx Supporting Statement A
Addendum - 0759 (Final).docx Supplementary Document
Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111) Form

All Historical Document Collections

202204-0960-006 Approved without change	Revision of a currently approved collection	2022-09-02
201901-0960-007 Approved with change	Revision of a currently approved collection	2019-05-24
201601-0960-007 Approved without change	Revision of a currently approved collection	2016-04-28
201302-0960-006 Approved without change	Revision of a currently approved collection	2013-05-29
201006-0960-012 Approved without change	Revision of a currently approved collection	2010-08-12
200903-0960-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2009-06-02
200705-0960-007 Approved with change	Existing collection in use without an OMB Control Number	2007-09-07