Form SSA-10 Application for Social Security Benefits

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Represents Change # on the Addendum

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Represents Change # on the Addendum

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Represents Change # on the Addendum

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Represents Change # on the Addendum

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See Revised PRA
Statement attached

SSA will insert the following revised PRA Statement into the form as soon
as possible:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. We estimate that it will take about
30 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments regarding this burden estimate or any other aspect of this collection,
including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.

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Represents Change # on the Addendum

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