Information Collection

Application for Widow's or Widower's Insurance Benefits--Paper Version

IC 8871 under ICR 200609-0960-025 · OMB 0960-0004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0004 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-10-BK Application for Widow's or Widower's Insurance Benefits--Paper Version Form
SSA-10-BK Application for Widow's or Widower's Insurance Benefits SSA-10-BK.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Widow's or Widower's Insurance Benefits--Paper Version	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.603 20 CFR 404.335-404.338

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-10-BK	Application for Widow's or Widower's Insurance Benefits	SSA-10-BK.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17,078	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	17,078	2,650	14,428
Annual IC Time Burden (Hours)	4,270	663	3,607
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.