Information Collection

Application for Child's Insurance Benefits / Life Claim / SSA-4-BK

IC 45023 under ICR 200805-0960-007 · OMB 0960-0010.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0010 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4-BK Application for Child's Insurance Benefits / Life Claim / SSA-4-BK	Form
SSA-4-BK Application for Child's Insurance Benefits SSA-4-BK.pdf	Form

IC Title:

Application for Child's Insurance Benefits / Life Claim / SSA-4-BK

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.603 20 CFR 416.350 20 CFR 404.350-404.368

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4-BK	Application for Child's Insurance Benefits	SSA-4-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: 46,250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	46,250	46,250
Annual IC Time Burden (Hours)	7,708	7,708
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.