Application for Widow's or Widower's Insurance Benefits

Forms and Documents

Document Name	Status
Form SSA-10 Application for Widow's or Widower's Insurance Benefits - Paper Version Form	Modified
Supporting Statement - 0004 (Final).docx Supporting Statement A	2022-06-01
Addendum - 0004 (Final).docx Supplementary Document	2022-06-01

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 - Modernized Claims System (MCS) Other-MCS Screens	Modified

ICR Details

OMB Control No: 0960-0004	ICR Reference No: 202202-0960-007
Status: Received in OIRA	Previous ICR Reference No: 201810-0960-018
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Widow's or Widower's Insurance Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/01/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2022
Responses	572,656	521,039
Time Burden (Hours)	286,328	121,614
Cost Burden (Dollars)	0	0

---

Abstract: SSA needs information to make a formal determination for entitlement to widow’s or widower’s benefits. We use Form SSA-10-BK to determine whether an applicant meets the statutory and regulatory conditions for entitlement to widow’s or widower’s under the Old Age, Survivors, and Disability Insurance (OASDI) program. SSA employees interview individuals applying for benefits either face to-face or via telephone and enter the information into the Modernized Claims System (MCS). When MCS is temporary unavailable, technicians use the paper form to record the information. The respondents are applicants for widow’s or widower’s benefits.

---

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:
	87 FR 18456	03/30/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 33282	06/01/2022
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 - Modernized Claims System (MCS)
Application for Widow's or Widower's Insurance Benefits - Paper Version	SSA-10	Application for Social Security Benefits

---

ICR Summary of Burden

	Total Request	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	572,656	521,039	0	0	51,617	0
Annual Time Burden (Hours)	286,328	121,614	0	0	164,714	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: When we last cleared this IC in 2019, the burden was 121,614 hours. However, we are currently reporting a burden of 286,328 hours. This change stems from an increase in the number of responses from 521,039 to 572,656. In addition, we updated the completion time from 14 & 15 to 30 minutes. We made the correction to the average burden per response per our current management information data. We believe that 30 minutes is a better estimate for respondents to gather information, read the instructions, and to complete the form.

---

Annual Cost to Federal Government: $4,662,074

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

---

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: 06/01/2022

---