Representative Payee Report of Benefits and Dedicated Account

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-6233 Representative Payee Report of Benefits and Dedicated Account	Form and Instruction	Modified	Available
Addendum - 0576.docx	Supplementary Document	Uploaded 2015-09-04	Available
Supporting Statement - 0576.doc	Supporting Statement A	Uploaded 2015-09-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9534	Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665	Form and Instruction	Modified	Representative Payee Report of Benefits and Dedicated Account
9534	Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665	Other-Revised Privacy Act and Paperwork Reduction Act	Modified

ICR Details

OMB Control No: 0960-0576	ICR Reference No: 201506-0960-009
Status: Historical Active	Previous ICR Reference No: 201208-0960-010
Agency/Subagency: SSA	Agency Tracking No:
Title: Representative Payee Report of Benefits and Dedicated Account
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/07/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/04/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2018	36 Months From Approved	01/31/2016
Responses	30,000	0	30,000
Time Burden (Hours)	10,000	0	10,000
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA requires representative payees RPs to submit a written report accounting for the use of money paid to Social Security or SSI recipients, and to establish and maintain a dedicated account for these payments. SSA uses Form SSA-6233 to ensure the RPs are using the benefits for the recipient's current maintenance and personal needs, and the expenditures of funds from the dedicated account in compliance with the law. Respondents are RPs for SSI and Social Security recipients.

---

Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 37708	07/01/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 53608	09/04/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665	SSA-6233	Representative Payee Report of Benefits and Dedicated Account

---

ICR Summary of Burden

table that charts list 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	30,000	30,000	0	0	0	0
Annual Time Burden (Hours)	10,000	10,000	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:

---

Annual Cost to Federal Government: $231,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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

---

Common Form ICR:  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:

(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: 09/04/2015

---