Application for Widow's or Widower's Insurance Benefits - MCS/Signature Proxy

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⚠️ Notice: This information collection may be referencing outdated material.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
MCS Screen Shots.pdf Other-Internal Screens

Information Collection (IC) Details

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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internal Screens			MCS Screen Shots.pdf		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: 453,509	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	453,509	4,509	449,000
Annual IC Time Burden (Hours)	105,819	1,052	104,767
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.