Information Collection

Representative Payee Evaluation Report--State/Local Government

IC 181091 under ICR 201904-0960-003 · OMB 0960-0069.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0069 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-624-F5 Representative Payee Evaluation Report--State/Local Government	Form
SSA-624 - Revised PA and PRA Statements.pdf	Other-Revised PA and PRA Statements
SSA-624-F5 Representative Payee Evaluation Report SSA-624-F5 - Revised Version.pdf	Form
SSA-624-F5 - Current Version.pdf Current SSA-624-F5	IC Document

IC Title:

Representative Payee Evaluation Report--State/Local Government

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 404.2062 20 CFR 416.665

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-624-F5	Representative Payee Evaluation Report	SSA-624-F5 - Revised Version.pdf		Yes	No	Fillable Printable
Other-Revised PA and PRA Statements			SSA-624 - Revised PA and PRA Statements.pdf		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	40	-7,970	8,010
Annual IC Time Burden (Hours)	20	-3,985	4,005
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-624-F5	SSA-624-F5 - Current Version.pdf	08/01/2019

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