REPRESENTATIVE PAYEE QUESTIONNAIRE (INDIVIDUAL) AND REPRESENTATIVE PAYEE QUESTIONNAIRE (INSTITUTION)

ICR 199406-0960-005

OMB: 0960-0493

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0960-0493 199406-0960-005
Historical Active 199303-0960-007
SSA
REPRESENTATIVE PAYEE QUESTIONNAIRE (INDIVIDUAL) AND REPRESENTATIVE PAYEE QUESTIONNAIRE (INSTITUTION)
No material or nonsubstantive change to a currently approved collection   No
Emergency 06/07/1994
Approved with change 06/07/1994
Retrieve Notice of Action (NOA) 06/07/1994
  Inventory as of this Action Requested Previously Approved
09/30/1994 09/30/1994 06/30/1994
4,775,000 0 4,775,000
38,322 0 38,322
0 0 0

THE INFORMATION COLLECTED ON THESE TWO FORMS WILL BE USED BY THE SOCIA SECURITY ADMINISTRATION TO CREATE THE "MASTER REPRESENTATIVE FILE" DAT BASE, WHICH IS NOW REQUIRED BY LAW. THE RESPONDENTS WILL BE INDIVIDUA OR INSTITUTIONS/AGENCIES WHO ARE RECEIVING SOCIAL SECURITY PAYMENTS ON BEHALF OF A BENEFICIARY.

None
None


No

1
IC Title Form No. Form Name
REPRESENTATIVE PAYEE QUESTIONNAIRE (INDIVIDUAL) AND REPRESENTATIVE PAYEE QUESTIONNAIRE (INSTITUTION) SSA-6220, SSA-622

  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 4,775,000 4,775,000 0 0 0 0
Annual Time Burden (Hours) 38,322 38,322 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
06/07/1994


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