Information Collection

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

IC 8871 under ICR 200909-0960-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form SSA-10-BK Application for Widow's or Widower's Insurance Benefits--Paper Version	Form and Instruction
SSA-10-BK Application for Widow's or Widower's Insurance Benefits SSA-10BK and INST.pdf	Form and Instruction

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-10-BK	Application for Widow's or Widower's Insurance Benefits	SSA-10BK and INST.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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	17,078	17,078
Annual IC Time Burden (Hours)	4,270	4,270
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.