Information Collection

Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS)

IC 45019 under ICR 202210-0960-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form SSA-4-BK (Moderniz Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS) Form
SSA-4-BK (Moderniz Application for Child's Insurance Benefits MCS Screens for SSA-4.docx Form
SSA-4-BK (Moderniz Application for Child's Insurance Benefits MCS Screens for SSA-4.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS)	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4-BK (Modernized Claims System Screens)	Application for Child's Insurance Benefits	MCS Screens for SSA-4.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 227,999	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	227,999	23,222	204,777
Annual IC Time Burden (Hours)	246,999	209,457	37,542
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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