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
Justification for the Non-Substantive Changes - 0004.docx Justification for No Material/Nonsubstantive Change	2016-12-16

IC Document Collections

IC ID	Document Title	Status
8871	Application for Widow's or Widower's Insurance Benefits - Paper Version Form	Modified
44959	Application for Widow's or Widower's Insurance Benefits - MCS/Signature Proxy Other-Internal Screens	Unchanged

ICR Details

OMB Control No: 0960-0004	ICR Reference No: 201612-0960-002
Status: Historical Active	Previous ICR Reference No: 201512-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Widow's or Widower's Insurance Benefits
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/19/2016
	Date Received in OIRA: 12/16/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	03/31/2019	03/31/2019
Responses	455,554	0	455,554
Time Burden (Hours)	106,330	0	106,330
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA uses the information it collects on the SSA–10–BK to determine whether the applicant meets the statutory and regulatory conditions for entitlement to widow(er)'s Title II benefits. SSA needs this information to make a formal determination for entitlement to widow(er)'s benefits. SSA employees interview individuals applying for benefits either face-to-face or via telephone and enter the information on the paper form or into the Modernized Claims System (MCS). The respondents are applicants for widow(er)'s benefits. This is a Non-Substantive Change Request to make a minor language revision to one of the information sections of the SSA-10 (see Justification for the Non-Substantive Changes for more information).

---

Authorizing Statute(s): US Code: 42 USC 402 Name of Law: Social Security Act
  

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:
	80 FR 78811	12/17/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 8323	02/18/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
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	455,554	455,554	0	0	0	0
Annual Time Burden (Hours)	106,330	106,330	0	0	0	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:

---

Annual Cost to Federal Government: $2,504,028

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 12/16/2016

---