Supporting Statement for Form SSA-4-BK
Application for Child’s Insurance Benefits
20 CFR 404-350 – 404.368 and 404.603, CFR 416.350
OMB No. 0960-0010
Introduction/Authorizing Laws and Regulations
Title II of the Social Security Act (the Act) provides for the payment of monthly benefits to the children of an insured retired, disabled, or deceased worker. Section 202(d) of the Act contains the conditions, and requirements the applicant must meet when filing for an application.
20 CFR 404.350 – 404.368 and 20 CFR 404.603 of the Code of Federal Regulations, set forth the eligibility criteria for child’s benefits, and require the filing of an application so that SSA can make a determination on the applicant’s eligibility for such benefits. In for SSA to make order a determination, it is necessary to elicit from the applicant information as to date and place of birth, relationship, residence, etc. The form SSA-4-BK, Application for Child’s Insurance Benefits, elicits this information.
Section 20 CFR 416.350 of the Code of Federal Regulations, requires the Social Security Administration (SSA) discuss the Supplemental Security Income (SSI) program with every Title II applicant who is within two months of age 65 or older, or might qualify as a blind or disabled person and give the person a chance to file an application. If the individual does not file an SSI application when we discuss SSI, the filing of the Title II application is an oral inquiry for SSI. The question on the Title II application that asks if the individual wants to file for SSI serves as documentation of the Claimant’s intent. It also eliminates the need for manually documenting the claimant’s intent to file in the remarks portion of the application.
Description of Collection
SSA collects the information on Form SSA-4-BK to entitle children of living and deceased workers to monthly Social Security payments. The applicant completes Form SSA-4-BK by filing out the form and mailing it back to SSA, over the phone or a face-to-face interview. The respondents are guardians completing the form on behalf of the children of living or deceased workers, or the children of living or deceased workers.
Use of Information Technology to Collect the Information
In accordance with the agency’s government Paperwork Elimination Act plan, SSA created an electronic version of Form SSA-4-BK. Approximately 95% of the SSA-4-BK interviews are collected through our Modernized SSI Claims System (MSSICS) and the remaining 5% of interviews are collected on the paper Form SSA-4-BK.
Why We Cannot Use Duplicate Information
The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-4-BK, we would be unable to entitle children of living and deceased workers to monthly Social Security payments. Because we only collect the information on an as needed basis, we cannot collect it less frequently.
There are no technical or legal obstacles to burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published March 30, 2010, at 75 FR 15761. SSA published the second Notice on August 03, 2010, at 75 FR 45692. If we receive comments in response to the 30-day Notice, we will forward them to OMB.
We did not consult with the public on the revision of this form.
Payment or Gifts to Respondents
SSA does not provide payment or gifts to the respondents.
Assurances of Confidentiality
SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Form of Request |
Number of Respondents |
Response Time (minutes) |
Burden (hours) |
Life Claims (paper) |
8,052 |
12 |
1,610 |
Life Claims (MCS) |
152,983 |
12 |
30,597 |
Life Claims- Signature Proxy |
152,983 |
11 |
28,047 |
Death Claims (paper) |
19,061 |
12 |
3,812 |
Death Claims (MCS) |
362,150 |
12 |
72,430 |
Death Claims- Signature Proxy |
362,150 |
11 |
66,394 |
Totals |
1,057,379 |
|
202,890 |
The total burden for this ICR is 202,890 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden to the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $83,658.00. This estimate is a projection of the costs for printing and distributing the form, collecting the information, keying the information from a paper form, and processing the collection instrument.
Program Changes or Adjustments to the Information Collection Request
There has been a decrease in burden hours. This change stems from a decrease in the amount in applicants completing the paper form SSA-4-BK.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provision at 5 CFR 1320.8(b)(3).
B. Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/msword |
| File Title | Supporting Statement for Form SSA-3 |
| Author | Cynthia Mages |
| Last Modified By | 889123 |
| File Modified | 2010-08-03 |
| File Created | 2010-03-31 |