Information Collection

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

IC 8867 under ICR 202104-0960-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form SSA-5-BK (revised) Application for Mother's or Father's Insurance Benefits Application for Mother's of Father's Insurance Benefits / SSA-5-BK	Form and Instruction
SSA-5-INST - Revised Version.pdf	Instruction
SSA-5-INST - Revised Version.pdf	Instruction
SSA-5 -Revised PA and PRA Statements.pdf	Other-Revised Privacy Act and PRA St
SSA-5 -Revised PA and PRA Statements.pdf	Other-Revised Privacy Act and PRA St
SSA-5-BK (revised) Application for Mother's or Father's Insurance Benefits SSA-5 - Revised Version.pdf	Form and Instruction
SSA-5-BK (revised) Application for Mother's or Father's Insurance Benefits SSA-5 - Revised Version.pdf	Form and Instruction
SSA-5 - Current Version.pdf Current SSA-5-BK	IC Document
SSA-5 - Current Version.pdf Current SSA-5-BK	IC Document
SSA-5-INST - Current Version.pdf Current SSA-5-INST	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.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-5-BK (revised)	www.ssa.gov	No		Fillable Printable
Instruction		www.ssa.gov	Yes	No	Fillable Printable
Other-Revised Privacy Act and PRA Stastements for the SSA-5-INST		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: 28

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	28	-2,669	2,697
Annual IC Time Burden (Hours)	28	-646	674
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-5-BK		06/25/2021
Current SSA-5-INST		06/25/2021

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

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