Application for Mother's or Father's Insurance Benefits

Forms and Documents

Document Name	Status
Form SSA-5-BK (revised) Application for Mother's of Father's Insurance Benefits / SSA-5-BK Form and Instruction	Modified
Addendum - 0003.docx Supplementary Document	2018-04-09
Supporting Statement - 0003.docx Supporting Statement A	2018-04-09

IC Document Collections

IC ID	Document Title	Status
8867	Application for Mother's of Father's Insurance Benefits / SSA-5-BK Form and Instruction	Modified
45016	Application for Mother's of Father's Insurance Benefits / MCS Other-MCS Screens	Removed
45015	Application for Mother's of Father's Insurance Benefits Modernized Claims System (MCS) Other-MCS Screens	Modified

ICR Details

OMB Control No: 0960-0003	ICR Reference No: 201710-0960-007
Status: Historical Active	Previous ICR Reference No: 201411-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Mother's or Father's Insurance Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/03/2018
	Date Received in OIRA: 04/09/2018
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2021	36 Months From Approved	07/31/2018
Responses	26,032	0	53,700
Time Burden (Hours)	6,508	0	12,991
Cost Burden (Dollars)	0	0	0

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Abstract: The Social Security Act provides for payment of benefits to the widow/widower of an insured individual if the surviving spouse is caring for the deceased worker's child who is entitled to Social Security Benefits. SSA collects the information on the SSA-5-BK to entitle an individual to his/her mother's or father's insurance benefits. The respondents are individuals applying for their mother or father's benefits.

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

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 52088	11/09/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 4722	02/01/2018
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Application for Mother's of Father's Insurance Benefits / MCS
Application for Mother's of Father's Insurance Benefits / SSA-5-BK	SSA-5-BK (revised)	Application for Mother's or Father's Insurance Benefits
Application for Mother's of Father's Insurance Benefits Modernized Claims System (MCS)

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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	26,032	53,700	0	-26,045	-1,623	0
Annual Time Burden (Hours)	6,508	12,991	0	-6,511	28	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The decrease in burden from 12,991 to 6,508 hours stems from a decreased number of respondents for all collection methods. The figure reported in 2014 was an estimate based on old data. In this ICR, we were able to obtain more accurate management information data for the number of respondents for both MCS and paper versions, and we adjusted our figures accordingly. Finally, we removed the additional MCS IC from this ICR, which we inadvertently did not remove previously once we instituted Signature Proxy for all MCS users. Because we are removing the old MCS IC now, this ICR shows a program change of -6,511 hours. However, as we made this change in 2014 prior to receiving OMB approval in 2015, we have no actual program change at this time (other than for the removal of the IC we inadvertently did not remove for the previous submission of this ICR). We realize we should have removed the IC as soon as possible after OMB approved the previous submission, which is why we are remedying this oversight now. The revisions we are making to the SSA-5-BK are informative only, and they will not change the overall burden for this ICR (see Addendum for more information). We will make the same informative changes to the MCS screens upon OMB’s approval of this ICR..

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Annual Cost to Federal Government: $27,382

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? Uncollected

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Common Form ICR:  No

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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: 04/09/2018

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