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

Application for Mother's or Father's Insurance Benefits

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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).pdf www.ssa.gov Form and Instruction
SSA-5-BK (current).pdf Current SSA-5-BK IC Document

Information Collection (IC) Details

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:

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).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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,697	2,697
Annual IC Time Burden (Hours)	674	674
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-5-BK	SSA-5-BK (current).pdf	10/10/2018

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