Statement of Death by Funeral Director

ICR 201612-0960-007

OMB: 0960-0142

Federal Form Document

Forms and Documents
Supplementary Document
Supporting Statement A
IC Document Collections
ICR Details
0960-0142 201612-0960-007
Active 201401-0960-002
Statement of Death by Funeral Director
Revision of a currently approved collection   No
Approved without change 11/03/2017
Retrieve Notice of Action (NOA) 05/02/2017
In accordance with 5 CFR 1320, the information collection is approved for three years.
  Inventory as of this Action Requested Previously Approved
11/30/2020 36 Months From Approved 11/30/2017
703,638 0 319,811
46,909 0 21,321
0 0 0

When an SSA-insured worker dies, the funeral director or funeral home responsible for the worker’s burial or cremation completes Form SSA-721 and sends it to SSA. SSA uses this information for three purposes: (1) to establish proof of death for the insured worker; (2) to determine if the insured individual was receiving any pre-death benefits SSA needs to terminate; and (3) to ascertain which surviving family member is eligible for the lump-sum death payment or for other death benefits. The respondents are funeral directors who handled death arrangements for the insured individuals.

US Code: 42 USC 402 Name of Law: Social Security Act

Not associated with rulemaking

  82 FR 3838 01/12/2017
82 FR 15412 03/28/2017

IC Title Form No. Form Name
Report of Death by Funeral Director SSA-721 Statement of Death by Funeral Director

  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 703,638 319,811 0 0 383,827 0
Annual Time Burden (Hours) 46,909 21,321 0 0 25,588 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
The increase in burden hours stems from an increase in the number of respondents due to more accurate management information regarding the number of respondents for this form, which indicates a significant increase in the use of the form since the last OMB approval. When cleared three years ago, we inadvertently used inaccurate information regarding the number of respondents. The number of respondents has been increasing incrementally over the years from 383,827 to 703,638. Our current estimate shows more accurate, recent data.

Faye Lipsky 410 965-8783 [email protected]


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:
    (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;
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.

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