Application for Child's Insurance Benefits / Life Claim / SSA-4-BK

Application for Child's Insurance Benefits

OMB: 0960-0010

IC ID: 45023

Information Collection (IC) Details

View Information Collection (IC)

Application for Child's Insurance Benefits / Life Claim / SSA-4-BK
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 416.350 20 CFR 404.350-404.368 20 CFR 404.603

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form SSA-4-BK Application for Child's Insurance Benefits SSA-4-BK (revised).pdf Yes No Fillable Printable
Instruction SSA-4-Inst (revised).pdf Yes No Paper Only

Income Security General Retirement and Disability

 

2,180 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,180 0 0 -1,304 0 3,484
Annual IC Time Burden (Hours) 436 0 0 -261 0 697
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Application for Child's Insurance Benefits (Current) SSA-4-BK (current).pdf 10/20/2022
SSA-4-INST - Current SSA-4-Inst (current).pdf 10/20/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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