Information Collection

Next of Kin

IC 188610 under ICR 201005-0925-001 · OMB 0925-0414.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0414 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SS_A_Attachment_5-Next_of_Kin_Questionnaire_Instructions.pdf	Instruction
2 questionaire SS_A_Attachment_4-Next_of_Kin_Questionnaires.pdf	Form
1 F24 Retention Worksheet F24 Retention Wksht.PDF	Form
SSA_Attachment 2_Next of Kin Data Collection List.pdf SSA_Attachment 2_Next of Kin Data Collection List	IC Document

IC Title:

Next of Kin

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			SS_A_Attachment_5-Next_of_Kin_Questionnaire_Instructions.pdf	Yes	Yes	Paper Only
Form	2	questionaire	SS_A_Attachment_4-Next_of_Kin_Questionnaires.pdf	Yes	Yes	Paper Only
Form	1	F24 Retention Worksheet	F24 Retention Wksht.PDF	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 941

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	941	-222	1,163
Annual IC Time Burden (Hours)	78	-19	97
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA_Attachment 2_Next of Kin Data Collection List	SSA_Attachment 2_Next of Kin Data Collection List.pdf	03/31/2010

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