Application for Mother's or Father's Insurance Benefits

OMB 0960-0003

The Social Security Act provides for payment of benefits to the widow/widower of an insured individual if the surviving spouse is caring for the deceased worker's child who is entitled to Social Security Benefits. SSA collects the information on the SSA-5-BK to entitle an individual to his/her mother's or father's insurance benefits. The respondents are individuals applying for their mother or father's benefits. This is a non-substantive Change Request to include the new Preliminary Claims System screens.

The latest form for Application for Mother's or Father's Insurance Benefits expires 2021-07-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-5-BK (revised) Application for Mother's of Father's Insurance Benefits / SSA-5-BK Form and Instruction
Addendum - 0003.docx Supplementary Document
Supporting Statement - 0003.docx Supporting Statement A
Application for Mother's of Father's Insurance Benefits / SSA-5-BK Form and Instruction
Application for Mother's of Father's Insurance Benefits Modernized Claims System (MCS) and Preliminary Claims System (PCS) Other-MCS Screens

All Historical Document Collections

202104-0960-002 Approved with change	Revision of a currently approved collection	2021-06-25
201902-0960-007 Approved without change	No material or nonsubstantive change to a currently approved collection	2019-02-13
201810-0960-005 Approved with change	No material or nonsubstantive change to a currently approved collection	2018-10-10
201710-0960-007 Approved with change	Revision of a currently approved collection	2018-04-09
201411-0960-001 Approved without change	Revision of a currently approved collection	2015-02-27
201111-0960-012 Approved without change	Revision of a currently approved collection	2012-03-26
200810-0960-007 Approved with change	Revision of a currently approved collection	2009-02-05
200805-0960-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2008-05-19
200608-0960-022 Approved without change	No material or nonsubstantive change to a currently approved collection	2006-09-01
200512-0960-004 Approved with change	Revision of a currently approved collection	2005-12-12
200409-0960-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2004-09-29
200209-0960-002 Approved with change	Revision of a currently approved collection	2002-09-09
199909-0960-002 Approved without change	Revision of a currently approved collection	1999-09-03
199606-0960-001 Approved without change	Extension without change of a currently approved collection	1996-06-07
199302-0960-006 Approved without change	Extension without change of a currently approved collection	1993-02-19
199002-0960-004 Approved without change	Extension without change of a currently approved collection	1990-02-15
198705-0960-003 Approved without change	Extension without change of a currently approved collection	1987-05-12
198408-0960-009 Approved without change	Revision of a currently approved collection	1984-08-22
198209-0960-002 Approved without change	Revision of a currently approved collection	1982-09-20
198110-0960-007 Approved without change	Revision of a currently approved collection	1981-10-02
198008-0960-008 Approved without change	Revision of a currently approved collection	1980-08-20
197911-0960-003 Approved without change	Revision of a currently approved collection	1979-11-20
197909-0960-009 Approved with change	No material or nonsubstantive change to a currently approved collection	1979-09-28
197903-0960-028 Approved with change	No material or nonsubstantive change to a currently approved collection	1979-03-28
197806-0960-005 Approved without change	Revision of a currently approved collection	1978-06-26
197804-0960-018 Approved with change	No material or nonsubstantive change to a currently approved collection	1978-04-07
197804-0960-017 Approved with change	No material or nonsubstantive change to a currently approved collection	1978-04-07
197711-0960-012 Approved with change	No material or nonsubstantive change to a currently approved collection	1977-11-30

OMB Details

Application for Mother's of Father's Insurance Benefits / SSA-5-BK

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form SSA-5-BK (revised)	Application for Mother's or Father's Insurance Benefits	www.ssa.gov	Form and instruction
Form		www.ssa.gov	Other
Form		www.ssa.gov	Instruction
Form		www.ssa.gov	Other

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.