Addendum - 0719

Addendum to Supporting Statement for Form SSA-445

Application to Collect a Fee for Payee Services

20 CFR 404.2040a & 416.640a

OMB No. 0960-0719

Minor Revisions to the Collection Instrument

SSA is making the following revision:

• Change #1: We are updating the instructions to specify that fee-for-service payee applicants must provide the required documentation necessary to process their applications, including a letter describing that the organization meets the community‑based criteria, a copy of the organization’s bond or insurance policy, and a copy of the state license. The new instructions will read as below:

I understand that I must provide the following documents along with this application:

• Our organization's mission statement; and

• A list of current beneficiaries being served (if applicable) including name, address, and SSN.

If my organization is NOT a state or local government agency, I must also provide the following:

• Proof of tax exempt status under Sec. 501(c) of the Internal Revenue Code;

• A copy of our bonding and/or insurance policy;

• A copy of our state license (provided that licensing is available in the state); and

• A letter describing that our organization meets the community-based criteria.

Justification #1: This change will help the agency determine whether the representative payee meets the requirements that non-government social service agencies are community-based, and are bonded, insured, and licensed, if licensing is available in the state, as required by 20 CFR 404.2040a & 416.640a.

• Change #2: We are revising the PRA statement on this form.

Justification #2: We are revising the PRA statement to reflect our current boilerplate language.  The current language, which dates back to the last reprint of the form, is now outdated.