Get Ssa-4111 2019

1. Signature of Witness Address Number and street City State and ZIP Code Form SSA-4111 12-2013 EF 12-2013 Destroy Prior Editions over Privacy Act Statement Collection and Use of Personal Information Sections 202 e f and q 3 of the Social Security Act as amended authorize us to collect this information. We will use the information you provide to determine your eligibility for reduced benefits as a widow er or a surviving divorced spouse. Form Approved OMB No* 0960-0759 Social Security Administration CERTIFICATE OF ELECTION FOR REDUCED WIDOW ER S AND SURVIVING DIVORCED SPOUSE S BENEFITS 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 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. INFORMATION ON HOW BENEFITS ARE AFFECTED IF THE DECEASED WORKER RECEIVED REDUCED RETIREMENT BENEFITS If the deceased worker received retirement benefits before FRA the maximum survivor s benefit is limited to the higher amount that the deceased worker would have received if still alive or 82. 5 percent of the deceased worker s unreduced benefit. Because of this limit delaying receipt of reduced benefits will not necessarily increase the monthly benefit amount payable. We will review your election in item 3 below to make sure that the month selected maximizes your benefit amount. 3. I elect to accept permanently reduced benefits as provided in Section 202 q of the MONTH YEAR Enter any month beginning with the month of the deceased worker s death up to but not including the month you reach FRA provided that the month you choose is within the past 12 months. I declare under penalty of perjury that I have examined all the information on this form and on any accompanying statements or forms and it is true and correct to the best of my knowledge. Signature First name middle initial last name Write in ink Date Month day year Telephone Number include area code Mailing Address Number and street Apt.