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 and PCS Form	Modified
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 / Modernized Claims System (MCS) and Preliminary Claims System (PCS) Form	Modified
Addendum - 0010.docx Supplementary Document	2019-09-20
Supporting Statement - 0010.docx Supporting Statement A	2019-09-20

IC Document Collections

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

ICR Details

OMB Control No: 0960-0010	ICR Reference No: 201906-0960-004
Status: Active	Previous ICR Reference No: 201902-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Child's Insurance Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/23/2019
	Date Received in OIRA: 09/20/2019
Terms of Clearance: Before resubmission, the agency shall evaluate whether parts of this collection can be eliminated by utilizing the agency's administrative data. Specifically questions about the deceased beneficiary.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2022	36 Months From Approved	12/31/2019
Responses	631,732	0	680,056
Time Burden (Hours)	115,896	0	125,034
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the information on Form SSA-4-BK to determine entitlement for children of living and deceased workers to monthly Social Security payments. Respondents are guardians completing the form on behalf of the children of living or deceased workers, or the children of living or deceased workers. Respondents can complete Form SSA 4 BK and mail it back to SSA, or an SSA employee can interview respondents and enter information into out Modernized Claims Systems (MCS), and Preliminary Claims System (PCS).

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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:
	84 FR 31972	07/03/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 48694	09/16/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

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) and Preliminary Claims System (PCS)	SSA-4-BK (Modernized Claims System Screens)	Application for Child's Insurance Benefits
Application for Child's Insurance Benefits / Life Claim / MCS and PCS	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	631,732	680,056	0	0	-48,324	0
Annual Time Burden (Hours)	115,896	125,034	0	0	-9,138	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: When we last cleared this ICR in 2016, the burden was 125,034 hours. However, we are currently reporting a burden of 115,896 hours. This change stems a decrease in the number of responses from 125,034 to 115,896. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change.

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Annual Cost to Federal Government: $4,278,781

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 09/20/2019

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