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

Application for Child's Insurance Benefits

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form SSA-4-BK Application for Child's Insurance Benefits / Death Claim / SSA-4-BK Form
SSA4-INST NEW (revised).pdf Instruction
SSA-4-BK Application for Child's Insurance Benefits SSA4 NEW (revised).pdf Form
ssa4-INST OLD.pdf Application for Child's Insurance Benefits (Current) IC Document
ssa4-INST OLD.pdf Application for Child's Insurance Benefits Instructions (Current) IC Document

Information Collection (IC) Details

IC Title:	Application for Child's Insurance Benefits / Death Claim / SSA-4-BK	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 416.350 20 CFR 404.350-.368

Information Collection 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	SSA4 NEW (revised).pdf		No		Paper Only
Instruction			SSA4-INST NEW (revised).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: 19,061	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	19,061	-21,689	40,750
Annual IC Time Burden (Hours)	3,812	-6,376	10,188
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Application for Child's Insurance Benefits (Current)	ssa4-INST OLD.pdf	05/05/2010
Application for Child's Insurance Benefits Instructions (Current)	ssa4-INST OLD.pdf	05/05/2010

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