Application for Widow's or Widower's Insurance Benefits - Paper Version

Application for Widow's or Widower's Insurance Benefits

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0004 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-10-BK Application for Widow's or Widower's Insurance Benefits - Paper Version Form and Instruction
SSA-10-INST - Revised Version.pdf Instruction
SSA-10-BK Application for Widow's or Widower's Insurance Benefits SSA-10-BK - Revised Version.pdf Form and Instruction
SSA-10-BK - Current Version.pdf Current SSA-10-BK IC Document
SSA-10-INST - Current Version.pdf Current SSA-10-INST IC Document

Information Collection (IC) Details

IC Title:	Application for Widow's or Widower's Insurance Benefits - Paper Version	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 404.603 20 CFR 404.335-404.338

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-10-BK	Application for Widow's or Widower's Insurance Benefits	SSA-10-BK - Revised Version.pdf		No		Paper Only
Instruction			SSA-10-INST - Revised Version.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,000	-12,078	17,078
Annual IC Time Burden (Hours)	1,250	-3,020	4,270
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-10-BK	SSA-10-BK - Current Version.pdf	11/23/2012
Current SSA-10-INST	SSA-10-INST - Current Version.pdf	11/23/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.