Application to Act as Representative Payee

Forms and Documents

Document Name	Status
Form RB-5 Application for Substitution of Payee and Duties As Representative Payee (Individuals) Form and Instruction	Modified
Form G-478 (Proposed) Statement Regarding Patient's Capability to Manage Payments Form and Instruction	Modified
Form RB-5 Application for Substitution of Payee and Duties as Representative Payee (Institutions) Form and Instruction	Modified
3220-0052.doc Supporting Statement A	2016-10-21

IC Document Collections

IC ID	Document Title	Status
33865	Application for Substitution of Payee and Duties As Representative Payee (Individuals) Form and Instruction	Modified
179885	Statement Regarding Patient's Capability to Manage Payments Form and Instruction	Modified
179617	Application for Substitution of Payee and Duties as Representative Payee (Institutions) Form and Instruction	Modified

ICR Details

OMB Control No: 3220-0052	ICR Reference No: 201608-3220-001
Status: Historical Active	Previous ICR Reference No: 201308-3220-001
Agency/Subagency: RRB	Agency Tracking No:
Title: Application to Act as Representative Payee
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: 12/12/2016
	Date Received in OIRA: 10/26/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved	12/31/2016
Responses	20,300	0	20,300
Time Burden (Hours)	16,350	0	16,350
Cost Burden (Dollars)	0	0	0

---

Abstract: Under Section 12 of the Railroad Retirement Act, the Railroad Retirement Board (RRB) may pay benefits to a representative payee when an employee, spouse or survivor annuitant is incompetent or is a minor. The collection obtains information related to the representative payee application, supporting documentation and the maintenance of records pertaining to the receipt and use of benefits.

---

Authorizing Statute(s): US Code: 45 USC 231k Name of Law: Railroad Retirement Act
   US Code: 45 USC 231f Name of Law: Railroad Retirement 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:
	81 FR 54856	08/17/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 73156	10/24/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Application for Substitution of Payee and Duties As Representative Payee (Individuals)	AA-5, RB-5, AA-5 (Proposed), RB-5 (proposed)	RB-5 Booklet; Your Duties as Representative Payee - Representative Payee's Record ,   Application for Substitution of Payee ,   RB-5 Booklet: Your Duties as Representative Payee-Representative Payee's Record ,   Application for Substitution of Payee
Statement Regarding Patient's Capability to Manage Payments	G-478 (Proposed), G-478	Statement Regarding Patient's Capability to Manage Payments ,   Statement Regarding Patient's Capability to Manage Payments
Application for Substitution of Payee and Duties as Representative Payee (Institutions)	AA-5, RB-5, AA-5 (proposed), RB-5 (Proposed)	Your Duties as Representative Payee-Representative's Payee's Record ,   Application for Substitution of Payee ,   RB-5 Booklet: Your Duties as Representative Payee-Representative Payee's Record ,   Application for Substitution of Payee

---

ICR Summary 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	20,300	20,300	0	0	0	0
Annual Time Burden (Hours)	16,350	16,350	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: $0

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? Yes

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: 10/26/2016

---