Information Collection

Application for Widow's or Widower's Insurance Benefits - Paper Version

IC 8871 under ICR 201612-0960-002 · OMB 0960-0004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0004 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-10-BK Application for Widow's or Widower's Insurance Benefits - Paper Version	Form
SSA-10-INST (revised).pdf	Instruction
SSA-10-BK Application for Widow's or Widower's Insurance Benefits SSA-10 - Revised Version.pdf	Form
SSA-10 - Current Version.pdf Current SSA-10-BK	IC Document

IC Title:

Application for Widow's or Widower's Insurance Benefits - Paper Version

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 404.603 20 CFR 404.335-404.338

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-10-BK	Application for Widow's or Widower's Insurance Benefits	SSA-10 - Revised Version.pdf		Yes	No	Fillable Printable
Instruction			SSA-10-INST (revised).pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,045

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	2,045	2,045
Annual IC Time Burden (Hours)	511	511
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-10-BK	SSA-10 - Current Version.pdf	12/16/2016

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