Application for Child's Insurance Benefits / Life Claim / MCS and PCS

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⚠️ Notice: This information collection may be referencing outdated material.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 (Moderniz Application for Child's Insurance Benefits / Life Claim / MCS and PCS Form
PCS Screen Package.pdf Other-PCS Screen Package
PCS Privacy Act Statement.pdf Other-Updated Privacy Act Statement
SSA-4-BK (Moderniz Application for Child's Insurance Benefits screens for ssa-4 (3).doc Form

Information Collection (IC) Details

IC Title:	Application for Child's Insurance Benefits / Life Claim / MCS and PCS	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 404.350-404.368 20 CFR 404.603

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4-BK (Modernized Claims System version)	Application for Child's Insurance Benefits	screens for ssa-4 (3).doc	Yes	Yes	Fillable Fileable Signable
Other-PCS Screen Package			PCS Screen Package.pdf	Yes	No	Fillable Printable
Other-Updated Privacy Act Statement for the PCS Screens			PCS Privacy Act Statement.pdf	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 465,428	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	465,428	465,428
Annual IC Time Burden (Hours)	85,328	85,328
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.