Information Collection

Application for Mother's of Father's Insurance Benefits / SSA-5-BK

IC 8867 under ICR 201710-0960-007 · OMB 0960-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0003 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5-BK (revised) Application for Mother's of Father's Insurance Benefits / SSA-5-BK	Form and Instruction
SSA-5-BK - Revised PA and PRA Statements.pdf www.ssa.gov	Other-Revised Privacy Act and PRA St
SSA-5-INST - Revised Version.pdf www.ssa.gov	Instruction
SSA-5-INST - Revised PA and PRA Statements.pdf www.ssa.gov	Other-Revised Privacy Act and PRA St
SSA-5-BK (revised) Application for Mother's or Father's Insurance Benefits SSA-5-BK - Revised Version.pdf www.ssa.gov	Form and Instruction
SSA-5-BK - Current Version.pdf Current SSA-5-BK	IC Document
SSA-5-INST - Current Version.pdf Current SSA-5-INST	IC Document

IC Title:

Application for Mother's of Father's Insurance Benefits / SSA-5-BK

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 404.601-404.603 20 CFR 404.339-404.342

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 and Instruction	SSA-5-BK (revised)	Application for Mother's or Father's Insurance Benefits	SSA-5-BK - Revised Version.pdf	www.ssa.gov	No		Fillable Printable
Other-Revised Privacy Act and PRA Statements			SSA-5-BK - Revised PA and PRA Statements.pdf	www.ssa.gov	No		Printable Only
Instruction			SSA-5-INST - Revised Version.pdf	www.ssa.gov	Yes	No	Fillable Printable
Other-Revised Privacy Act and PRA Stastements for the SSA-5-INST			SSA-5-INST - Revised PA and PRA Statements.pdf	www.ssa.gov	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,697

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,697	1,086	1,611
Annual IC Time Burden (Hours)	674	271	403
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-5-BK	SSA-5-BK - Current Version.pdf	04/09/2018
Current SSA-5-INST	SSA-5-INST - Current Version.pdf	04/09/2018

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