Application for Survivor's Benefits

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-24 Application for Survivor's Benefits	Form and Instruction	Modified	Available
Supporting Statement - 0062.docx	Supporting Statement A	Uploaded 2017-03-27	Available
Addendum - 0062.docx	Supplementary Document	Uploaded 2017-03-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8991	Application for Survivor's Benefits	Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0062	ICR Reference No: 201612-0960-003
Status: Active	Previous ICR Reference No: 201602-0960-015
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Survivor's 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: 09/21/2017
	Date Received in OIRA: 03/27/2017
Terms of Clearance: · In accordance with 5 CFR 1320, the information collection is approved for three years.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2020	36 Months From Approved	09/30/2017
Responses	3,200	0	3,200
Time Burden (Hours)	800	0	800
Cost Burden (Dollars)	0	0	0

---

Abstract: Surviving family members of armed services personnel can file for benefits at SSA or the Veterans Administration (VA) to be considered for benefits at either agency. If applicants go to the VA first, they complete form SSA-24, the Application for Survivor's Benefits. The VA then forwards form SSA-24 to SSA for processing. If applicants previously filed for benefits at SSA, the agency disregards this form. The respondents are survivors of deceased armed services personnel who are applying for benefits at the VA.

---

Authorizing Statute(s): US Code: 42 USC 402 Name of Law: Social Security Act
   US Code: 38 USC 5105 Name of Law: Veterans' Benefits
  

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 96160	12/29/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 13372	03/10/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Application for Survivor's Benefits	VA Form 21-534, SSA-24	Application for Survivor's Benefits ,   Department of Veterans Affairs: Application for Dependency and Indemnity Compensation, Death Pension and Accured Benefits by a Surving Spouse or Child (Including Death Compensation if Applicable)

---

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	3,200	3,200	0	0	0	0
Annual Time Burden (Hours)	800	800	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $4,298

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 03/27/2017

---