Information Collection

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

IC 8867 under ICR 201411-0960-001 · OMB 0960-0003.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5-BK (revised) Application for Mother's of Father's Insurance Benefits / SSA-5-BK	Form and Instruction
PRA.doc	Other-Revised Paperwork Reduction Ac
Revised Privacy Act Statement.doc	Other-Revised Privacy Act Statement
SSA-5-BK (revised) Application for Mother's or Father's Insurance Benefits SSA-5-BK Fillable DRAFT.pdf	Form and Instruction
Current SSA-5-BK (2).pdf SSA-5-BK(current)	IC Document

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 404.339-404.342 20 CFR 404.601-404.603

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	SSA-5-BK (revised)	Application for Mother's or Father's Insurance Benefits	SSA-5-BK Fillable DRAFT.pdf	No	Paper Only
Other-Revised Paperwork Reduction Act			PRA.doc	No	Paper Only
Other-Revised Privacy Act Statement			Revised Privacy Act Statement.doc	No	Printable 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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
SSA-5-BK(current)	Current SSA-5-BK (2).pdf	12/08/2014

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