Application for Lump-Sum Death Payment

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-8-F4 Application for Lump-Sum Death Payment - Paper	Form	Unchanged	Available
PCS Questions.pdf	Supplementary Document	Uploaded 2019-02-11	Available
Justification for the Non-Substantive Changes - 0960-0013.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2019-02-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8890	Application for Lump-Sum Death Payment - Paper	Form	Unchanged
44962	Application for Lump-Sum Death Payment--Modernized Claims System (MCS)	Other-Internal Use Screens	Modified

ICR Details

OMB Control No: 0960-0013	ICR Reference No: 201902-0960-006
Status: Historical Active	Previous ICR Reference No: 201603-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Lump-Sum Death Payment
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/25/2019
	Date Received in OIRA: 02/13/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	08/31/2019	08/31/2019
Responses	670,248	0	670,248
Time Burden (Hours)	100,674	0	100,674
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses Form SSA-8-F4 to collect information needed to authorize payment of the lump-sum death payment (LSDP) to a widow, widower, or children as defined in Section 202(i) of the Act. Respondents complete the application for this one-time payment via paper form, telephone, or during an in-person interview with SSA employees. Respondents are applicants for the LSDP. This is a non-substantive Change Request to include the new Preliminary Claims System screens.

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Authorizing Statute(s): US Code: 42 USC 402 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 19283	04/04/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 39990	06/20/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Application for Lump-Sum Death Payment--Modernized Claims System (MCS)
Application for Lump-Sum Death Payment - Paper	SSA-8-F4	Application For Lump-Sum Death Payment

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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	670,248	670,248	0	0	0	0
Annual Time Burden (Hours)	100,674	100,674	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:

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Annual Cost to Federal Government: $89,841

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

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Common Form ICR:  No

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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: 02/13/2019

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