Information Collection

Application for Wife's or Husband's Insurance Benefits (MCS Screens Signature Proxy)

IC 179343 under ICR 200701-0960-020 · OMB 0960-0618.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0618 can be found here:

Documents and Forms

Document Name Document Type
ssa2_mcs.pdf Other-MCS Screens

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Wife's or Husband's Insurance Benefits (MCS Screens Signature Proxy)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404 Subpart D, G & P 20 CFR 404.315-.322 20 CFR 404.310-.311 20 CFR 404.330-.333 20 CFR 404.1501-.1512 20 CFR 404.601-.603

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-MCS Screens			ssa2_mcs.pdf		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 332,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	332,500	332,500
Annual IC Time Burden (Hours)	77,583	77,583
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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