Application for Mother's of Father's Insurance Benefits / SSA-5-BK

Application for Mother's or Father's Insurance Benefits

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0003 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-5-BK Application for Mother's of Father's Insurance Benefits / SSA-5-BK Form and Instruction
SSA-5-BK Application for Mother's or Father's Insurance Benefits ssa5bk(revised).pdf Form and Instruction
ssa5bk.pdf SSA-5-BK(current) IC Document

Information Collection (IC) Details

IC Title:	Application for Mother's of Father's Insurance Benefits / SSA-5-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 404.601-404.603 20 CFR 404.339-404.342

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-5-BK	Application for Mother's or Father's Insurance Benefits	ssa5bk(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: 1,611	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,611	1,611
Annual IC Time Burden (Hours)	403	403
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-5-BK(current)	ssa5bk.pdf	12/20/2011

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