Information Collection

SSA-10 (Upload Documents)

IC 280625 under ICR 202605-0960-005 · OMB 0960-0004.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-10 Application for Widow’s or Widower’s Insurance Benefits SSA-10 (Upload Documents)	Form and Instruction
SSA-10 Application for Widow’s or Widower’s Insurance Benefits SSA 10 (current).pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.335-404.338 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 and Instruction	SSA-10				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: 1,516

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,516	1,516
Annual IC Time Burden (Hours)	65,188	65,188
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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