Application for Widow's or Widower's Insurance Benefits

Forms and Documents

Document Name	Status
Form SSA-10-BK Application for Widow's or Widower's Insurance Benefits--Paper Version Form	Modified
Supporting Statement--0004(F).doc Supporting Statement A	2006-09-22

IC Document Collections

IC ID	Document Title	Status
8871	Application for Widow's or Widower's Insurance Benefits--Paper Version Form	Modified
44960	Application for Widow's or Widower's Insurance Benefits--Modernized Claims System (MCS) Other-Modernized Claims System Version of the SSA-10-BK	Modified
44959	Application for Widow's or Widower's Insurance Benefits--MCS/Signature Proxy Other-Modernized Claims System Version of the SSA-10-BK	Modified

ICR Details

OMB Control No: 0960-0004	ICR Reference No: 200609-0960-025
Status: Historical Active	Previous ICR Reference No: 200608-0960-018
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Widow's or Widower's Insurance Benefits
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/15/2006
	Date Received in OIRA: 09/25/2006
Terms of Clearance: This ICR is approved on the condition that grammatical errors and other such non-substantive errors should be corrected when this form is next printed.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2009	36 Months From Approved	12/31/2006
Responses	341,560	0	288,580
Time Burden (Hours)	82,686	0	69,860
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA uses the information collected on Form SSA-10-BK to determine whether the applicant meets the statutory and regulatory conditions for entitlement to widow's or widower's Social Security Title II benefits. The respondents are applicants for widow's or widower's Social Security benefits.

---

Authorizing Statute(s): US Code: 42 USC 402 Name of Law: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 34180	06/13/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 54705	09/18/2006
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Application for Widow's or Widower's Insurance Benefits--Modernized Claims System (MCS)
Application for Widow's or Widower's Insurance Benefits--Paper Version	SSA-10-BK	Application for Widow's or Widower's Insurance Benefits
Application for Widow's or Widower's Insurance Benefits--MCS/Signature Proxy

---

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	341,560	288,580	0	0	52,980	0
Annual Time Burden (Hours)	82,686	69,860	0	0	12,826	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: The increase in the public reporting burden is due to an increase in the number of respondents for the widow(er)'s benefits.

---

Annual Cost to Federal Government: $2,104,010

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 09/25/2006

---