Information Collection

Application to Collect A Fee for Payee Services

IC 9776 under ICR 201707-0960-011 · OMB 0960-0719.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0719 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-445 Application to Collect A Fee for Payee Services	Form
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-445 Application to Collect a Fee for Payee Services (State/l SSA-445 - Revised.pdf	Form
SSA-445 - Current.pdf SSA-445 (Current)	IC Document

IC Title:

Application to Collect A Fee for Payee Services

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.2040(a) 20 CFR 416.640(a)

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-445	Application to Collect a Fee for Payee Services (State/local government)	SSA-445 - Revised.pdf		No		Paper Only
Other-Revised PA Statement			Revised PA Statement.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-445 (Current)	SSA-445 - Current.pdf	10/11/2017

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