Application for Lump-Sum Death Payment--MCS with Electronic Signature (Signature Proxy)

Application for Lump-Sum Death Payment, 404.390 - 404.392

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0013 can be found here:

Documents and Forms

Document Name Document Type
MCS LSDP.doc Other-Modernized Claims Systems Scre

Information Collection (IC) Details

IC Title:	Application for Lump-Sum Death Payment--MCS with Electronic Signature (Signature Proxy)	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 404.390-404.392

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Modernized Claims Systems Screens for SSA-8-F4			MCS LSDP.doc		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 278,825	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	278,825	-137,750	416,575
Annual IC Time Burden (Hours)	41,824	-20,662	62,486
Annual IC Cost Burden (Dollars)	0	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.