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
Justification for Non-Substantive Changes - 0003 (Final).docx Justification for No Material/Nonsubstantive Change	2025-03-13
Supporting Statement - 0003 (Final).docx Supporting Statement A	2024-07-23

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
45015	Application for Mother's of Father's Insurance Benefits Modernized Claims System (MCS) and Preliminary Claims System (PCS) Other-MCS Screens	Unchanged

ICR Details

OMB Control No: 0960-0003	ICR Reference No: 202503-0960-003
Status: Received in OIRA	Previous ICR Reference No: 202104-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Mother's or Father'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	Date Submitted to OIRA: 03/14/2025

	Requested	Previously Approved
Expiration Date	08/31/2027	08/31/2027
Responses	23,151	23,151
Time Burden (Hours)	32,400	32,400
Cost Burden (Dollars)	0	0

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Abstract: Section 202(g) of the Social Security Act (Act) provides for the payment of monthly benefits to the widow or widower of an insured individual if the surviving spouse is caring for the deceased worker’s child (who is entitled to Social Security benefits). The Social Security Administration (SSA) uses the information on Form SSA-5-BK to determine an individual’s eligibility for mother’s or father’s insurance benefits. The respondents are individuals caring for a child of the deceased worker who is applying for mother’s or father’s insurance benefits under the Old Age, Survivors, and Disability Insurance program. We are submitting this Change Request to revise the form to align with the E.O. 14168, Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government, and to remove requests for pension information as per the Social Security Fairness Act of 2023 (SSFA), which repealed the WEP and Government Pension Offset (GPO) provisions for benefits payable for months after December 2023.

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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:
	86 FR 17874	04/06/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 33007	06/23/2021
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 / 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) and Preliminary Claims System (PCS)

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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	23,151	23,151	0	0	0	0
Annual Time Burden (Hours)	32,400	32,400	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:

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Annual Cost to Federal Government: $309,476

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

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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: 03/14/2025

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