Information Collection

Application for Survivor's Benefits

IC 8991 under ICR 201612-0960-003 · OMB 0960-0062.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0062 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-24 Application for Survivor's Benefits	Form and Instruction
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-24 Application for Survivor's Benefits SSA-24 - Revised.pdf	Form and Instruction
VA Form 21-534 Department of Veterans Affairs: Application for Dependen VA Form 21-534.pdf	Form and Instruction
SSA-24 - Current.pdf SSA-24 - Current	IC Document

IC Title:

Application for Survivor's Benefits

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.611(c) 20 CFR 404.611(a)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-24	Application for Survivor's Benefits	SSA-24 - Revised.pdf	Yes	No	Fillable Printable
Form and Instruction	VA Form 21-534	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)	VA Form 21-534.pdf	No		Printable Only
Other-Revised PA Statement			Revised PA Statement.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: 3,200

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

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-24 - Current	SSA-24 - Current.pdf	02/21/2017

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