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Application for Child's Insurance Benefits / Life Claim / SSA-4-BK
Application for Child's Insurance Benefits
OMB: 0960-0010
IC ID: 45023
OMB.report
SSA
OMB 0960-0010
ICR 202603-0960-013
IC 45023
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Application for Child's Insurance Benefits / Life 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 404.350-404.368
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 (revised).pdf
Yes
No
Fillable Printable
Other-SSA-4-BK Privacy Act Statement Revised
Privacy Act Statement revised.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
2,912
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
2,912
0
0
732
0
2,180
Annual IC Time Burden (Hours)
1,019
0
0
583
0
436
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Application for Child's Insurance Benefits (Current)
SSA-4-BK (current).pdf
03/23/2026
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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