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

Application for Widow's or Widower's Insurance Benefits

Documents and Forms

Document Name Document Type
Form SSA-10 Application for Widow's or Widower's Insurance Benefits - Paper Version Form
SSA-10 Application for Social Security Benefits SSA-10 - Revised.pdf Form
SSA-10 - Current.pdf SSA-10 - Current 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 404.335-404.338 20 CFR 404.603

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-10	Application for Social Security Benefits	SSA-10 - Revised.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,116	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,116	-139	2,255
Annual IC Time Burden (Hours)	1,058	494	564
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-10 - Current	SSA-10 - Current.pdf	06/01/2022

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