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

Application for Mother's or Father's Insurance Benefits

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-INST - Revised Version.pdf www.ssa.gov Instruction
SSA-5 -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 - Revised Version.pdf www.ssa.gov Form and Instruction
SSA-5 - Current Version.pdf Current SSA-5-BK IC Document
SSA-5-INST - Current Version.pdf Current SSA-5-INST 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 - Revised Version.pdf	www.ssa.gov	No		Fillable Printable
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 -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: 28	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	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)	7	-667	674
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-5-BK	SSA-5 - Current Version.pdf	06/25/2021
Current SSA-5-INST	SSA-5-INST - Current Version.pdf	06/25/2021

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