Information Collection

Application for Child's Insurance Benefits / Life Claim / SSA-4-BK

IC 45023 under ICR 201906-0960-004 · OMB 0960-0010.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0010 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4-BK Application for Child's Insurance Benefits / Life Claim / SSA-4-BK	Form
SSA-4-INST (revised).pdf	Instruction
SSA-4-BK Application for Child's Insurance Benefits SSA-4-BK (revised).pdf	Form
SSA-4-BK (current).pdf Application for Child's Insurance Benefits (Current)	IC Document
SSA-4-INST (current).pdf SSA-4-INST - Current	IC Document

IC Title:

Application for Child's Insurance Benefits / Life Claim / SSA-4-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 416.350 20 CFR 404.350-404.368 20 CFR 404.603

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	SSA-4-BK	Application for Child's Insurance Benefits	SSA-4-BK (revised).pdf		No		Fillable Printable
Instruction			SSA-4-INST (revised).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,484

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	3,484	-11,723	15,207
Annual IC Time Burden (Hours)	697	-2,344	3,041
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Application for Child's Insurance Benefits (Current)	SSA-4-BK (current).pdf	07/16/2019
SSA-4-INST - Current	SSA-4-INST (current).pdf	07/16/2019

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