Application for Child's Insurance Benefits

Forms and Documents

Document Name	Status
Form SSA-4-BK Application for Child's Insurance Benefits / Death Claim / SSA-4-BK Form	Modified
Form SSA-4-BK (Moderniz Application for Child's Insurance Benefits / Life Claim / MCS Form	Unchanged
Form SSA-4-BK (Moderniz Application for Child's Insurance Benefits / Life Claim / MCS / Signature Proxy Form	Unchanged
Form SSA-4-BK Application for Child's Insurance Benefits / Life Claim / SSA-4-BK Form	Modified
Form SSA-4-BK (Moderniz Application for Child's Insurance Benefits / Death Claim/MCS Form	Unchanged
Form SSA-4-BK (Moderniz Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS)/ Signature Proxy Form	Unchanged
Justification for a Non-Substantive Changes - 0010.doc Justification for No Material/Nonsubstantive Change	2015-05-20

IC Document Collections

IC ID	Document Title	Status
8883	Application for Child's Insurance Benefits / Death Claim / SSA-4-BK Form	Modified
45025	Application for Child's Insurance Benefits / Life Claim / MCS Form	Unchanged
45024	Application for Child's Insurance Benefits / Life Claim / MCS / Signature Proxy Form	Unchanged
45023	Application for Child's Insurance Benefits / Life Claim / SSA-4-BK Form	Modified
45021	Application for Child's Insurance Benefits / Death Claim/MCS Form	Unchanged
45019	Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS)/ Signature Proxy Form	Unchanged

ICR Details

OMB Control No: 0960-0010	ICR Reference No: 201505-0960-015
Status: Historical Active	Previous ICR Reference No: 201305-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Child's Insurance Benefits
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/14/2015
	Date Received in OIRA: 05/21/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2016	11/30/2016	11/30/2016
Responses	955,500	0	955,500
Time Burden (Hours)	183,342	0	183,342
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the information collected on the SSA-4-BK to entitle children of living and deceased workers to monthly Social Security payments. Respondents complete the form on behalf of the children of living or deceased workers This is a Non-Substantive Change Request to add a new fillable PDF modality to this ICR.

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Authorizing Statute(s): US Code: 42 USC 404(d) Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 32529	05/30/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 49592	08/14/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Application for Child's Insurance Benefits / Life Claim / SSA-4-BK	SSA-4-BK	Application for Child's Insurance Benefits
Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS)/ Signature Proxy	SSA-4-BK (Modernized Claims System Screens)	Application for Child's Insurance Benefits
Application for Child's Insurance Benefits / Death Claim/MCS	SSA-4-BK (Modernized Claims System Screens)	Application for Child's Insurance Benefits
Application for Child's Insurance Benefits / Life Claim / MCS / Signature Proxy	SSA-4-BK (Modernized Claims System version)	Application for Child's Insurance Benefits
Application for Child's Insurance Benefits / Life Claim / MCS	SSA-4-BK (Modernized Claims System version)	Application for Child's Insurance Benefits
Application for Child's Insurance Benefits / Death Claim / SSA-4-BK	SSA-4-BK	Application for Child's Insurance Benefits

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	955,500	955,500	0	0	0	0
Annual Time Burden (Hours)	183,342	183,342	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $83,658

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/21/2015

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