Request to be Selected as a Payee

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-11-BK Individuals/Households: Paper SSA-11-BK	Form	Modified	Available
Form SSA-11 RPS Screens State/Local/Tribal Government: RPS	Form	Modified	Available
Form SSA-11-BK State/Local/Tribal Government: Paper SSA-11-BK	Form	Modified	Available
Form SSA-11 RPS Screens Private Sector: RPS	Form	Modified	Available
Form SSA-11-BK Private Sector: Paper SSA-11-BK	Form	Modified	Available
Justification for the Non-Substantive Changes - 0014.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-11-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8897	Individuals/Households: Paper SSA-11-BK	Form	Modified
44953	Individuals/Households: Representative Payee System (RPS)	Other-Internal Use Screens	Modified
186315	State/Local/Tribal Government: RPS	Form	Modified
186313	State/Local/Tribal Government: Paper SSA-11-BK	Form	Modified
186312	Private Sector: RPS	Form	Modified
186310	Private Sector: Paper SSA-11-BK	Form	Modified

ICR Details

OMB Control No: 0960-0014	ICR Reference No: 201511-0960-004
Status: Historical Active	Previous ICR Reference No: 201303-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Request to be Selected as a Payee
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/05/2016
	Date Received in OIRA: 12/18/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2016	07/31/2016	07/31/2016
Responses	1,700,000	0	1,700,000
Time Burden (Hours)	311,666	0	311,666
Cost Burden (Dollars)	0	0	0

---

Abstract: An individual applying to be a representative payee for a Social Security beneficiary or SSI recipient must first complete Form SSA-11-BK. SSA obtains information from applicant payees regarding their relationship to the beneficiary, personal qualifications, concerns for the beneficiary's well-being, and intended use of benefits if appointed as payee. The respondents are individuals, private sector businesses and institutions, and State and local government institutions and agencies applying to become representative payees. Non-Substantive changes are being made to update the form with current needs-based assistance programs as well as to adopt new policy. In addition, the RPS screens were redesigned, but request no new information.

---

Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
   PL: Pub.L. 108 - 203 103 & 203 Name of Law: Social Security Protection Act of 2004
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 203 103 & 203 Name of Law: Social Security Protection Act of 2004

---

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:
	78 FR 19794	04/02/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 33142	06/03/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Private Sector: Paper SSA-11-BK	SSA-11-BK	Request to be Selected as Payee
State/Local/Tribal Government: Paper SSA-11-BK	SSA-11-BK	Request to be Selected as a Payee
State/Local/Tribal Government: RPS	SSA-11 RPS Screens	Request to be Selected as Payee
Individuals/Households: Representative Payee System (RPS)
Individuals/Households: Paper SSA-11-BK	SSA-11-BK	Request to be Selected as a Payee
Private Sector: RPS	SSA-11 RPS Screens	Request to be Selected as Payee

---

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	1,700,000	1,700,000	0	0	0	0
Annual Time Burden (Hours)	311,666	311,666	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: $8,135,745

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: 12/18/2015

---