Application for Mother's or Father's Insurance Benefits

Forms and Documents

Document	Type	Status	Availability
Form SSA-5-BK (revised) Application for Mother's of Father's Insurance Benefits / SSA-5-BK	Form and Instruction	Modified	Available
Addendum 0003 (revised).doc	Supplementary Document	Uploaded 2015-02-23	Available
SSA-5-BK Supporting Statement (revised).doc	Supporting Statement A	Uploaded 2015-03-19	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
8867	Application for Mother's of Father's Insurance Benefits / SSA-5-BK	Form and Instruction	Modified
45016	Application for Mother's of Father's Insurance Benefits / MCS	Other-MCS Screens	Modified
45015	Application for Mother's of Father's Insurance Benefits Modernized Claims System (MCS) / Signature Proxy	Other-MCS Screens	Unchanged

ICR Details

OMB Control No: 0960-0003	ICR Reference No: 201411-0960-001
Status: Historical Active	Previous ICR Reference No: 201111-0960-012
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Mother's or Father's Insurance Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/27/2015
	Date Received in OIRA: 02/27/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2018	36 Months From Approved	04/30/2015
Responses	53,700	0	53,700
Time Burden (Hours)	12,991	0	12,991
Cost Burden (Dollars)	0	0	0

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Abstract: The Social Security Act provides for payment of benefits to the widow/widower of an insured individual if the surviving spouse is caring for the deceased worker's child who is entitled to Social Security Benefits. SSA collects the information on the SSA-5-BK to entitle an individual to his/her mother's or father's insurance benefits. The respondents are individuals applying for their mother or father's benefits.

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Authorizing Statute(s): US Code: 42 USC 402 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 72237	12/05/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 9499	02/23/2015
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Application for Mother's of Father's Insurance Benefits Modernized Claims System (MCS) / Signature Proxy
Application for Mother's of Father's Insurance Benefits / MCS
Application for Mother's of Father's Insurance Benefits / SSA-5-BK	SSA-5-BK (revised)	Application for Mother's or Father's Insurance Benefits

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	53,700	53,700	0	0	0	0
Annual Time Burden (Hours)	12,991	12,991	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $413,490

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/27/2015

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