OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Application for Widow's or Widower's Insurance Benefits

OMB 0960-0004 · SSA.

OMB 0960-0004

SSA needs information to make a formal determination for entitlement to widow’s or widower’s benefits. We use Form SSA-10-BK to determine whether an applicant meets the statutory and regulatory conditions for entitlement to widow’s or widower’s under the Old Age, Survivors, and Disability Insurance (OASDI) program. SSA employees interview individuals applying for benefits either face to-face or via telephone and enter the information into the Modernized Claims System (MCS). When MCS is temporary unavailable, technicians use the paper form to record the information. The respondents are applicants for widow’s or widower’s benefits. We are submitting this Change Request to remove requests for pension information as per the Social Security Fairness Act of 2023 (SSFA), which repealed the WEP and Government Pension Offset (GPO) provisions for benefits payable for months after December 2023.

The latest form for Application for Widow's or Widower's Insurance Benefits expires 2026-07-31 and is listed under ICR 202503-0960-004.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form SSA-10 Application for Social Security BenefitsForm
Form SSA-10 Application for Widow’s or Widower’s Insurance BenefitsForm and Instruction
Addendum - 0004.docxSupplementary Document
Supporting Statement - 0004.docxSupporting Statement A
Application for Widow's or Widower's Insurance Benefits - Paper Version Form
Application for Widow's or Widower's Insurance Benefits - Paper Version Other-Privacy Act Statement (revised)
Application for Widow's or Widower's Insurance Benefits - Modernized Claims System (MCS) -In-person Interview Other-MCS Screens
SSA-10 (MCS/Telephone Interview) Other-MCS Screens
SSA-10 (Upload Documents) Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202605-0960-005 Revision of a currently approved collection 2026-06-26
202503-0960-004 No material or nonsubstantive change to a currently approved collection 2025-03-14 Approved without change
202202-0960-007 Revision of a currently approved collection 2022-06-01 Approved without change
201810-0960-018 Revision of a currently approved collection 2019-02-26 Approved without change
201612-0960-002 No material or nonsubstantive change to a currently approved collection 2016-12-16 Approved without change
201512-0960-002 Revision of a currently approved collection 2016-02-24 Approved without change
201409-0960-005 No material or nonsubstantive change to a currently approved collection 2014-09-09 Approved without change
201211-0960-002 Revision of a currently approved collection 2013-03-11 Approved without change
200909-0960-005 Revision of a currently approved collection 2009-12-08 Approved without change
200805-0960-006 No material or nonsubstantive change to a currently approved collection 2008-05-19 Approved without change
200609-0960-025 Extension without change of a currently approved collection 2006-09-25 Approved with change
200608-0960-018 No material or nonsubstantive change to a currently approved collection 2006-09-01 Approved without change
200310-0960-011 Extension without change of a currently approved collection 2003-10-31 Approved without change
200212-0960-011 Revision of a currently approved collection 2002-12-23 Approved without change
199911-0960-005 Reinstatement with change of a previously approved collection 1999-11-08 Approved without change
199909-0960-008 No material or nonsubstantive change to a currently approved collection 1999-09-23 Approved without change
199608-0960-007 Extension without change of a currently approved collection 1996-08-16 Approved without change
199307-0960-006 Extension without change of a currently approved collection 1993-07-26 Approved without change
199005-0960-006 Revision of a currently approved collection 1990-05-14 Approved without change
198908-0960-010 No material or nonsubstantive change to a currently approved collection 1989-08-25 Approved with change
198706-0960-002 Revision of a currently approved collection 1987-06-23 Approved without change
198409-0960-012 No material or nonsubstantive change to a currently approved collection 1984-09-26 Approved with change
198408-0960-003 Revision of a currently approved collection 1984-08-15 Approved without change
198302-0960-009 Revision of a currently approved collection 1983-02-28 Approved without change
198209-0960-003 Revision of a currently approved collection 1982-09-29 Approved without change
198110-0960-005 Revision of a currently approved collection 1981-10-02 Approved without change
198009-0960-004 Revision of a currently approved collection 1980-09-09 Approved without change
197912-0960-003 Revision of a currently approved collection 1979-12-21 Approved without change
197909-0960-010 No material or nonsubstantive change to a currently approved collection 1979-09-28 Approved with change
197809-0960-015 No material or nonsubstantive change to a currently approved collection 1978-09-28 Approved with change
197807-0960-006 Revision of a currently approved collection 1978-07-26 Approved without change
197804-0960-019 No material or nonsubstantive change to a currently approved collection 1978-04-07 Approved with change
197711-0960-013 No material or nonsubstantive change to a currently approved collection 1977-11-30 Approved with change

OMB Details

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

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Information collection instruments
FormNameElectronic accessType
Form SSA-10Application for Social Security BenefitsFillable PrintableForm

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.