Information Collection

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

IC 45023 under ICR 202603-0960-013 · OMB 0960-0010.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4-BK Application for Child's Insurance Benefits Application for Child's Insurance Benefits / Life Claim / SSA-4-BK	Form
Privacy Act Statement revised.docx	Other-SSA-4-BK Privacy Act Statement
SSA-4-BK Application for Child's Insurance Benefits SSA-4-BK (revised).pdf	Form
SSA-4-BK (current).pdf Application for Child's Insurance Benefits (Current)	IC Document

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4-BK				Yes	No	Fillable Printable
Other-SSA-4-BK Privacy Act Statement Revised					No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,912

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,912	732	2,180
Annual IC Time Burden (Hours)	1,019	583	436
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Application for Child's Insurance Benefits (Current)		03/23/2026

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

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