Application for Child's Insurance Benefits

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-4-BK Application for Child's Insurance Benefits	Form	Modified	Available
Form SSA-4-BK (Moderniz Application for Child's Insurance Benefits	Form	Removed	Repair queued
Form SSA-4-BK (Moderniz Application for Child's Insurance Benefits	Form	Modified	Available
Form SSA-4-BK Application for Child's Insurance Benefits	Form	Modified	Repair queued
Form SSA-4-BK (Moderniz Application for Child's Insurance Benefits	Form	Removed	Repair queued
Form SSA-4-BK (Moderniz Application for Child's Insurance Benefits	Form	Modified	Available
Addendum - 0010.docx	Supplementary Document	Uploaded 2016-10-28	Available
Supporting Statement - 0010.docx	Supporting Statement A	Uploaded 2016-10-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8883	Application for Child's Insurance Benefits / Death Claim / SSA-4-BK	Form	Modified	Application for Child's Insurance Benefits
8883	Application for Child's Insurance Benefits / Death Claim / SSA-4-BK	Instruction	Modified
45025	Application for Child's Insurance Benefits / Life Claim / MCS	Form	Removed	Application for Child's Insurance Benefits
45024	Application for Child's Insurance Benefits / Life Claim / MCS / Signature Proxy	Form	Modified	Application for Child's Insurance Benefits
45023	Application for Child's Insurance Benefits / Life Claim / SSA-4-BK	Form	Modified	Application for Child's Insurance Benefits
45023	Application for Child's Insurance Benefits / Life Claim / SSA-4-BK	Instruction	Modified
45021	Application for Child's Insurance Benefits / Death Claim/MCS	Form	Removed	Application for Child's Insurance Benefits
45019	Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS)/ Signature Proxy	Form	Modified	Application for Child's Insurance Benefits

ICR Details

OMB Control No: 0960-0010	ICR Reference No: 201607-0960-011
Status: Historical Active	Previous ICR Reference No: 201505-0960-015
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Child'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: 12/12/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/28/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved	12/31/2016
Responses	680,056	0	955,500
Time Burden (Hours)	125,034	0	183,342
Cost Burden (Dollars)	0	0	0

---

Abstract: Title II of the Social Security Act (Act) provides for the payment of monthly benefits to children of an insured retired, disabled, or deceased worker. Section 202(d) of the Act discloses the conditions and requirements the applicant must meet when filing an application. SSA uses the information on Form SSA-4-BK to determine entitlement for children of living and deceased workers to monthly Social Security payments. Respondents are guardians completing the form on behalf of the children of living or deceased workers, or the children of living or deceased workers.

---

Authorizing Statute(s): US Code: 42 USC 404(d) Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 51957	08/05/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 73189	10/24/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS)/ Signature Proxy	SSA-4-BK (Modernized Claims System Screens)	Application for Child's Insurance Benefits
Application for Child's Insurance Benefits / Death Claim / SSA-4-BK	SSA-4-BK	Application for Child's Insurance Benefits
Application for Child's Insurance Benefits / Death Claim/MCS	SSA-4-BK (Modernized Claims System Screens)	Application for Child's Insurance Benefits
Application for Child's Insurance Benefits / Life Claim / MCS	SSA-4-BK (Modernized Claims System version)	Application for Child's Insurance Benefits
Application for Child's Insurance Benefits / Life Claim / MCS / Signature Proxy	SSA-4-BK (Modernized Claims System version)	Application for Child's Insurance Benefits
Application for Child's Insurance Benefits / Life Claim / SSA-4-BK	SSA-4-BK	Application for Child's Insurance Benefits

---

ICR Summary of Burden

table that charts list 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	680,056	955,500	0	190,056	-465,500	0
Annual Time Burden (Hours)	125,034	183,342	0	34,792	-93,100	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: The decrease in burden hours stems from a decrease in the number of respondents. Our new burden reflects current management information data. In addition, since the last OMB Approval, we reduced our collections to only four. We removed the stand alone MCS collections, because they are now included in the MCS/Signature Proxy estimate since we require attestation (signature proxy) from all interviewees using MCS.

---

Annual Cost to Federal Government: $1,030,905

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

---

Common Form ICR:  No

---

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: 10/28/2016

---