Information Collection

State/Local/Tribal Government: RPS/Signature Proxy

IC 186314 under ICR 201303-0960-005 · OMB 0960-0014.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-11 RPS Screens State/Local/Tribal Government: RPS/Signature Proxy	Form
SSA-11 RPS Screens Request to be Selected as Payee RPS Screens.pdf	Form

IC Title:

State/Local/Tribal Government: RPS/Signature Proxy

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.601-416.665 20 CFR 404.2010-404.2055

Information Collection Instruments:

table that charts list of 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 Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-8,500	8,500
Annual IC Time Burden (Hours)	-1,346	1,346
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.