Application for Widow's or Widower's Insurance Benefits--Modernized Claims System (MCS)

Application for Widow's or Widower's Insurance Benefits

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0004 can be found here:

Documents and Forms

Document Name Document Type
MSOM Screen Shots for SSA-10BK.doc Other-Modernized Claims System Versi

Information Collection (IC) Details

IC Title:	Application for Widow's or Widower's Insurance Benefits--Modernized Claims System (MCS)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.603 20 CFR 404.335-404.338

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Modernized Claims System Version of the SSA-10-BK			MSOM Screen Shots for SSA-10BK.doc		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 162,241	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-162,241	162,241
Annual IC Time Burden (Hours)	-40,560	40,560
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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