Application for Mother's or Father's Insurance Benefits

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-5-BK (revised) Application for Mother's or Father's Insurance Benefits	Form and Instruction	Modified	Repair queued
Form SSA-5-BK (revised) Application for Mother's of Father's Insurance Benefits / SSA-5-BK	Form and Instruction	Modified	Repair queued
Addendum - 0003.docx	Supplementary Document	Uploaded 2021-06-25	Repair queued
Supporting Statement - 0003.docx	Supporting Statement A	Uploaded 2021-06-25	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8867	Application for Mother's of Father's Insurance Benefits / SSA-5-BK	Form and Instruction	Modified	Application for Mother's or Father's Insurance Benefits
8867	Application for Mother's of Father's Insurance Benefits / SSA-5-BK	Form and Instruction	Modified
8867	Application for Mother's of Father's Insurance Benefits / SSA-5-BK	Instruction	Modified
45015	Application for Mother's of Father's Insurance Benefits Modernized Claims System (MCS) and Preliminary Claims System (PCS)	Other-MCS Screens	Modified

ICR Details

OMB Control No: 0960-0003	ICR Reference No: 202104-0960-002
Status: Historical Active	Previous ICR Reference No: 201902-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Mother's or Father's Insurance Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/12/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/25/2021
Terms of Clearance: The agency made clarifications to the description of the information collection and use of evidence in the Supporting Statement. The agency revised the burden estimate upwards. The agency also made minor modifications to the form.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2027	36 Months From Approved	08/31/2024
Responses	23,151	0	26,032
Time Burden (Hours)	32,400	0	6,508
Cost Burden (Dollars)	0	0	0

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Abstract: Section 202(g) of the Social Security Act (Act) provides for the payment of monthly benefits to the widow or widower of an insured individual if the surviving spouse is caring for the deceased worker’s child (who is entitled to Social Security benefits). The Social Security Administration (SSA) uses the information on Form SSA-5-BK to determine an individual’s eligibility for mother’s or father’s insurance benefits. The respondents are individuals caring for a child of the deceased worker who is applying for mother’s or father’s insurance benefits under the Old Age, Survivors, and Disability Insurance program.

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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:
	86 FR 17874	04/06/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 33007	06/23/2021
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 Mother's of Father's Insurance Benefits / SSA-5-BK	SSA-5-BK (revised)	Application for Mother's or Father's Insurance Benefits
Application for Mother's of Father's Insurance Benefits Modernized Claims System (MCS) and Preliminary Claims System (PCS)

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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	23,151	26,032	0	0	-2,881	0
Annual Time Burden (Hours)	32,400	6,508	0	0	25,892	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: When we last cleared this information collection, we estimated 26,032 responses. We are updating the burden based on current management information data showing the number of annual responses for a recent twelve-month period was 23,151. Although the number of responses changed, SSA did not take any actions to cause this change. In addition, we also increased the overall burden per response by 15 minutes to account for the time it takes for respondents to collect the needed data to complete the information collection, and also updated the burden data in ROCIS to include the travel time of 30 minutes per response, which increased the overall burden for this collection. These figures represent current management information data. Finally, the minor revisions we are making to the SSA-5-BK will not change the overall burden for this collection (see Addendum for more information). * Note: The total burden reflected in ROCIS is 32,400, while the burden cited in #12 of the Supporting Statement is 11,576. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30 minute, one-way, drive burden. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

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Annual Cost to Federal Government: $309,476

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? No

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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: 06/25/2021

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