Application for Parent's Insurance Benefits / Modernized Claims System (MCS) Signature Proxy

Application for Parent's Insurance Benefits

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0012 can be found here:

Documents and Forms

Document Name Document Type
MCS screens SSA7.pdf Other-electronic screens
SSA-7 Revised Privacy Act Statement.doc Revised Privacy Act Statement IC Document

Information Collection (IC) Details

IC Title:	Application for Parent's Insurance Benefits / 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 601-.603 20 CFR 373-.374 20 CFR 370-.371 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-electronic screens			MCS screens SSA7.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: 158	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	158	158
Annual IC Time Burden (Hours)	37	37
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Revised Privacy Act Statement	SSA-7 Revised Privacy Act Statement.doc	04/03/2015

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