Information Collection

Application for Widow's or Widower's Insurance Benefits - Paper Version

IC 8871 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 Social Security Benefits Application for Widow's or Widower's Insurance Benefits - Paper Version	Form
Privacy Act Statement (revised).docx	Other-Privacy Act Statement (revised
SSA-10 Application for Social Security Benefits SSA-10 (revised).pdf	Form
SSA 10 (current).pdf SSA-10 - 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 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	SSA-10				Yes	No	Fillable Printable
Other-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: 1,845

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	1,845	-271	2,116
Annual IC Time Burden (Hours)	1,384	326	1,058
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-10 - Current		06/04/2026

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

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