Social Security Ex-Spouse Benefits Claim Form
Please complete all fields below to submit your Social Security Ex-Spouse Benefits Claim Form. Do not enter any sensitive identification numbers or financial details.
Your Full Name
*
First Name
Last Name
Your Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Email Address
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Ex-Spouse's Full Name
*
First Name
Last Name
Ex-Spouse's Date of Birth (if known)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Marriage
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Divorce
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Duration of Marriage (in years)
*
Your Current Marital Status
*
Single
Remarried
Widowed
Submit Claim
Should be Empty: