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 Request to be Selected as a Payee	Form	Modified	Available
Form SSA-11-BK Request to be Selected as a Payee	Form	Modified	Available
Form SSA-11-BK Request to be Selected as Payee	Form	Modified	Repair queued
Addendum 0014.doc	Supplementary Document	Uploaded 2019-03-27	Available
Supporting Statement 0014.doc	Supporting Statement A	Uploaded 2019-03-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8897	Individuals/Households: Paper SSA-11-BK	Form	Modified	Request to be Selected as a Payee
8897	Individuals/Households: Paper SSA-11-BK	Other-Privacy Act Statement (revised) 0014	Modified
44953	Individuals/Households: Representative Payee System (RPS)	Other-Internal Use Screens	Modified
186315	State/Local/Tribal Government: RPS	Other-Internal Use Screens	Modified
186313	State/Local/Tribal Government: Paper SSA-11-BK	Form	Modified	Request to be Selected as a Payee
186313	State/Local/Tribal Government: Paper SSA-11-BK	Other-Revised Privacy Act Statement 0014	Modified
186312	Private Sector: RPS	Other-Internal Screens	Modified
186310	Private Sector: Paper SSA-11-BK	Form	Modified	Request to be Selected as Payee
186310	Private Sector: Paper SSA-11-BK	Other-Privacy Act Statement (revised) 0014	Modified

ICR Details

OMB Control No: 0960-0014	ICR Reference No: 201812-0960-004
Status: Historical Active	Previous ICR Reference No: 201602-0960-014
Agency/Subagency: SSA	Agency Tracking No:
Title: Request to be Selected as a 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: 06/10/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/27/2019
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	36 Months From Approved	08/31/2019
Responses	1,975,580	0	1,700,000
Time Burden (Hours)	395,116	0	311,666
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA requires individuals applying to be representative payees for OASDI, or SSI recipients to complete Form SSA-11-BK or, supply the same information to a field office technician through a personal interview. SSA obtains information from applicant payees regarding their relationship to the recipient; personal qualifications; concerns for the recipient’s well-being; and intended use of payments if appointed as payee. SSA collects this on paper Form SSA-11-BK, or through eRPS, an electronic version of the form, which field office technicians complete during a face-to-face interview with the applicant. The respondents are individuals; private sector businesses and institutions; and State and local government institutions and agencies applying to become representative payees.

---

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
   PL: Pub.L. 115 - 165 103(a) & 104 Name of Law: Strengthening Protections for Social Security Act of 2018
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 203 103 & 203 Name of Law: Social Security Protection Act of 2004
PL: Pub.L. 115 - 165 103(a) & 104 Name of Law: Strengthening Protections for Social Security Act of 2018

---

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:
	84 FR 371	01/25/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 11625	03/27/2019
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
Individuals/Households: Paper SSA-11-BK	SSA-11-BK	Request to be Selected as a Payee
Individuals/Households: Representative Payee System (RPS)
Private Sector: Paper SSA-11-BK	SSA-11-BK	Request to be Selected as Payee
Private Sector: RPS
State/Local/Tribal Government: Paper SSA-11-BK	SSA-11-BK	Request to be Selected as a Payee
State/Local/Tribal Government: RPS

---

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	1,975,580	1,700,000	0	0	275,580	0
Annual Time Burden (Hours)	395,116	311,666	0	0	83,450	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: When we last cleared this IC in 2016, the burden was 311,666 hours. However, we are currently reporting a burden of 395,116. This change stems from SSA adding two additional questions to identify whether a child is in foster care and whether the applicant to be payee is a State Foster Care Agency due to the Public Law. There is no change to the burden time per response

---

Annual Cost to Federal Government: $10,047,799

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 03/27/2019

---