Form Ssa-4111 - Certification Of Election For Reduced Widow(Er)'S And Surviving Divorced Spouse'S Benefits Page 2

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Form SSA-4111 (08-2017) uf (08-2017)
Page 2 of 2
Privacy Act Statement
Collection and Use of Personal Information
Sections 202(e), (f) and (q) of the Social Security Act, as amended, authorize us to collect this information.
We will use the information you provide to make a determination regarding your eligibility for reduced benefits
as a widow(er) or surviving divorced spouse.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information
may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination regarding
benefits eligibility. However, we may use the information for the administration of our programs including
sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract
with us).
A list of when we may share your information with others, called routine uses, is available in our Privacy Act
System of Records Notices 60-0089, entitled Claims Folders Systems. Additional information about this and
other system of records notices and our programs is available online at
or at your
local Social Security office.
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 incorrect payments or delinquent debts under these programs.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we
display a valid Office of Management and Budget control number. We estimate that it will take about 2 minutes to read
the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA’s website at
. Offices are also listed under U. S. Government agencies in your telephone directory or
you may call Social Security at 1-800-772-1213 (TTY 1- 800-325-0778). You may send comments on our time
estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

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