State/Local/Tribal Government: RPS

Request to be Selected as Payee

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0014 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-11 RPS Screens State/Local/Tribal Government: RPS Form
SSA-11 RPS Screens Request to be Selected as Payee RPS Screens.pdf Form

Information Collection (IC) Details

IC Title:	State/Local/Tribal Government: RPS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.2010-404.2055 20 CFR 416.601-416.655

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-11 RPS Screens	Request to be Selected as Payee	RPS Screens.pdf		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,500	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	263	263
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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