OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

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

IC 8883 under ICR 202603-0960-013 · OMB 0960-0010.

Documents and Forms
Document Name
Document Type
Form
Other-SSA-4-BK Privacy Act Statement
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Application for Child's Insurance Benefits / Death Claim / SSA-4-BK
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 416.350 20 CFR 404.603 20 CFR 404.350-.368

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 Paper Only
Other-SSA-4-BK Privacy Act Statement Revised Privacy Act Statement revised.docx No   Paper Only

Income Security General Retirement and Disability

 

1,702 0
   
Individuals or Households
 
   0 %

  Requested 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 1,702 0 0 524 0 1,178
Annual IC Time Burden (Hours) 596 0 0 360 0 236
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SSA-4-BK SSA-4-BK (current).pdf 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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