Application for Lump-Sum Death Payment

Forms and Documents

Document	Type	Status	Availability
Form SSA-8-F4 Application for Lump-Sum Death Payment - Paper	Form	Modified	Repair queued
Addendum - 0013.doc	Supplementary Document	Uploaded 2010-05-24	Repair queued
Supporting Statement - 0013.doc	Supporting Statement A	Uploaded 2010-05-27	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
8890	Application for Lump-Sum Death Payment - Paper	Form	Modified
44962	Application for Lump-Sum Death Payment--Modernized Claims System (MCS)	Other-Internal Use Screens	Modified
44961	Application for Lump-Sum Death Payment--MCS with Electronic Signature (Signature Proxy)	Other-Internal Use Screens	Modified

ICR Details

OMB Control No: 0960-0013	ICR Reference No: 201002-0960-004
Status: Historical Active	Previous ICR Reference No: 200805-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Lump-Sum Death Payment
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/24/2010
	Date Received in OIRA: 05/27/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	36 Months From Approved	09/30/2010
Responses	587,000	0	587,000
Time Burden (Hours)	93,187	0	93,187
Cost Burden (Dollars)	0	0	0

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Abstract: The Social Security Administration collects information on Form SSA–8–F4 to authorize payment of the lump sum death payment (LSDP) to a widow, widower, or children as defined in Section 202(i) of the Act. Individual respondents complete the application for this one-time payment via paper form, telephone or in-person interview with SSA employees. Respondents are applicants for LSDP.

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Authorizing Statute(s): US Code: 42 USC 402 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 9992	03/04/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 29797	05/27/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Application for Lump-Sum Death Payment--Modernized Claims System (MCS)
Application for Lump-Sum Death Payment--MCS with Electronic Signature (Signature Proxy)
Application for Lump-Sum Death Payment - Paper	SSA-8-F4	Application For Lump-Sum Death Payment

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	587,000	587,000	0	0	0	0
Annual Time Burden (Hours)	93,187	93,187	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $89,841

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/27/2010

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