SSA-754

Statement Of Marital Relationship By One Of The Parties

Download and Print the SSA-754

All items on this form requiring an answer must be answered or marked "Unknown."

I understand that the information given by me will be used in connection with an application filed for insurance benefits payable under Title II of the Social Security Act, as amended, based on the earnings of the wage earner or self-employed person named below.
(Do not write in this space)

Privacy Act Notice: Section 216(h), of the Social Security Act, as amended, authorizes us to collect this information. We will use this information to make a determination on your claim. Furnishing us this information is voluntary. However, failure to provide all or part of the information could prevent us from making an accurate and timely decision on your benefit eligibility. We rarely use the information you supply for any purpose other than for making a determination relating to benefit eligibility. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following:

1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;

2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department of Veterans' Affairs);

3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and,

4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security). We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records Notices entitled, Claims Folder Record, 60-0089 and Master Beneficiary Record, 60-0090. These notices, additional information regarding this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.

1. PRINT NAME OF WAGE EARNER OR SELF EMPLOYED PERSON
SOCIAL SECURITY NUMBER
2. PRINT YOUR FULL NAME (First, middle initial, last)
3. NAME OF PERSON WITH WHOM YOU WERE LIVING:
4. WHEN DID YOU BEGIN LIVING TOGETHER IN A HUSBAND AND WIFE RELATIONSHIP?
MONTH - YEAR - WHERE DID YOU LIVE? - CITY OR TOWN - STATE

5. A. DID YOU LIVE TOGETHER CONTINUOUSLY SINCE THAT TIME? - YES - NO
If "No," give the periods of separation and the reasons why you did not live together.
B. Where have you lived together as husband and wife and for what periods of time?
CITY OR TOWN - STATE - DATES FROM TO

6. DID YOU HAVE AN UNDERSTANDING AS TO YOUR RELATIONSHIP WHEN YOU BEGAN LIVING TOGETHER? - YES - NO

And much more...