Representative Payee Report of Benefits and Dedicated Account

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-6233-BK Representative Payee Report of Benefits and Dedicated Account	Form and Instruction	Modified	Available
Form SSA-6233-BK Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665	Form and Instruction	Modified	Repair queued
Addendum - 0576 (Final).docx	Supplementary Document	Uploaded 2021-11-19	Repair queued
Supporting Statement - 0576 (Final).docx	Supporting Statement A	Uploaded 2021-11-24	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9534	Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665	Form and Instruction	Modified	Representative Payee Report of Benefits and Dedicated Account
9534	Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665	Form and Instruction	Modified
9534	Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665	Other-Revised PA and PRA Statements	Modified

ICR Details

OMB Control No: 0960-0576	ICR Reference No: 202104-0960-010
Status: Historical Active	Previous ICR Reference No: 201901-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Representative Payee Report of Benefits and Dedicated Account
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: 12/23/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/24/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2024	36 Months From Approved	12/31/2021
Responses	31,500	0	36,228
Time Burden (Hours)	10,500	0	12,076
Cost Burden (Dollars)	0	0	0

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Abstract: SSA requires payees to submit a written report accounting for the use of money paid to Social Security or Supplemental Security Income (SSI) recipients, and to establish and maintain a dedicated account for these payments. SSA uses Form SSA-6233-BK to: (1) Ensure the payee uses the payments for the recipient’s current maintenance and personal needs; and (2) confirm the expenditures of funds from the dedicated account remain in compliance with the law. Although we mail a paper Form SSA-6233-BK to the payee, the report can also be completed through telephone contact and then be mailed to the payee for signature, or during a face-to-face interview. The respondents are payees for SSI and Social Security recipients.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 47190	08/23/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 64585	11/18/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665	SSA-6233-BK	Representative Payee Report of Benefits and Dedicated Account

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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	31,500	36,228	0	0	-4,728	0
Annual Time Burden (Hours)	10,500	12,076	0	0	-1,576	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 2018, the burden was 12,076 hours. However, we are currently reporting a burden of 10,500 hours. This change stems from a decrease in the number of respondents from 36,228 to 31,500. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data.

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Annual Cost to Federal Government: $386,495

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? No

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Common Form ICR:  No

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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: 11/24/2021

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