Information Collection

Application for Child's Insurance Benefits / Life Claim / MCS / Signature Proxy

IC 45024 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form SSA-4-BK (Moderniz Application for Child's Insurance Benefits / Life Claim / MCS / Signature Proxy Form
SSA-4-BK (Moderniz Application for Child's Insurance Benefits screens for ssa-4 (3).doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Child's Insurance Benefits / Life Claim / 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 404.603 20 CFR 404.350-404.368 20 CFR 416.350

Information Collection 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 version)	Application for Child's Insurance Benefits	screens for ssa-4 (3).doc		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: 351,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	351,500	351,500
Annual IC Time Burden (Hours)	64,442	64,442
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.