Information Collection

Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS)/ Signature Proxy

IC 45019 under ICR 201505-0960-015 · OMB 0960-0010.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0010 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4-BK (Moderniz Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS)/ Signature Proxy	Form
SSA-4-BK (Moderniz Application for Child's Insurance Benefits SSA-4 SCreens.pdf	Form

IC Title:

Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS)/ Signature Proxy

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.350-404.368 20 CFR 404.603 20 CFR 416.350

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4-BK (Modernized Claims System Screens)	Application for Child's Insurance Benefits	SSA-4 SCreens.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 114,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	114,000	114,000
Annual IC Time Burden (Hours)	20,900	20,900
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.