Statement of Marital Relationship

form SSA-754-F4 (02-2016) UF (02-2016) Destroy Prior EditionsSOCIAL security ADMINISTRATIONSTATEMENT OF Marital Relationship (By one of the parties) form Approved OMB No. 0960-0038 Page 1 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.

Form SSA-754-F4 (02-2016) UF (02-2016) Destroy Prior Editions. SOCIAL SECURITY ADMINISTRATION. STATEMENT OF MARITAL RELATIONSHIP (By one of the parties) Form Approved OMB No. 0960-0038 ... DID YOU HAVE AN UNDERSTANDING AS TO YOUR RELATIONSHIP WHEN YOU BEGAN LIVING TOGETHER? A. If it was in writing, furnish a …

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