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

Application for Child's Insurance Benefits

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	Application for Child's Insurance Benefits / Death Claim / SSA-4-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 416.350 20 CFR 404.603 20 CFR 404.350-.368

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4-BK				Yes	No	Paper Only
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: 1,702	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	1,702	524	1,178
Annual IC Time Burden (Hours)	596	360	236
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-4-BK		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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