SSA-4111

Certification Of Election For Reduced Widow(er)'s And Surviving Divorced Spouse's Benefits

Download and Print the SSA-4111

Request may not be processed if the form is incomplete or illegible.

1. PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON (Hereafter called "Worker")
ENTER HIS OR HER SOCIAL SECURITY NUMBER

2. PRINT YOUR FULL NAME (First name, middle initial, last name)
ENTER YOUR SOCIAL SECURITY NUMBER (If "none" or "unknown" so indicate.)
INFORMATION ABOUT REDUCED WIDOW(ER)'S AND SURVIVING DIVORCED SPOUSE'S BENEFITS

The law requires that you complete and return this Certificate of Election if you wish to receive a reduced widow's, widower's or surviving divorced spouse's benefit and are at least age 62 and under full retirement age (FRA).

The following will affect the amount of your benefit:

The month and year you elect to begin to receive benefits will determine the amount of your monthly payments which will continue at a reduced rate even after you reach FRA.

Depending on your date of birth, the rate of reduction applied to your benefit amount can range from 19/40 to 19/56 of 1 percent times the number of months from the start of the reduced benefits until the month you reach FRA.

If another beneficiary is entitled to a monthly survivor benefit on this Social Security number, your benefit may be reduced by the total family benefit payable in the month. The benefit paid to a surviving divorced spouse will not affect the benefit amount paid to other family members who receive benefits on the same record.

And much more...