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

Application for Child's Insurance Benefits

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0010 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-4-BK Application for Child's Insurance Benefits / Death Claim / SSA-4-BK Form
SSA4-INST NEW (current).pdf Instruction
SSA-4-BK Application for Child's Insurance Benefits SSA-4-BK - New Fillable Version.pdf Form
SSA-4-BK - Current Version.pdf Application for Child's Insurance Benefits (Current) IC Document

Information Collection (IC) Details

IC Title:	Application for Child's Insurance Benefits / Death Claim / SSA-4-BK	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 416.350 20 CFR 404.350-.368 20 CFR 404.603

Information Collection Instruments:

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 - New Fillable Version.pdf		No		Paper Only
Instruction			SSA4-INST NEW (current).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	1,200	1,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Application for Child's Insurance Benefits (Current)	SSA-4-BK - Current Version.pdf	05/20/2015

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