Supporting Statement - 0576 (Final)

Supporting Statement - 0576 (Final).docx

Representative Payee Report of Benefits and Dedicated Account

OMB: 0960-0576

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Supporting Statement for Form SSA-6233-BK

Representative Payee Report of Benefits and Dedicated Account

20 CFR 416.546, 416.635, 416.640, 416.665

OMB No. 0960-0576

A. Justification

  1. Introduction/Authoring Laws and Regulations

Section 1631(a) of the Social Security Act (Act), and Sections 20 CFR 416.546, 416.640, 416.635 and 416.665 of the Code of Federal Regulations, require representative payees (payee) to establish and maintain a separate (i.e., “dedicated”) account in a financial institute when a blind or disabled child under age 18 is eligible for certain past-due Supplemental Security Income (SSI) monthly payments, on or after August 23, 1996. Per the regulations, the payee has the option to deposit certain subsequent past-due benefits and underpayments into the dedicated account. SSA restricts the funds from the account to specific purchases. SSA requires payees with dedicated accounts to report the activity of funds in the account annually, using Form SSA-6233-BK, to ensure deposits and expenditures comply with the law. This reporting requirement remains in effect either until the payee depletes the account, or until SSA terminates eligibility for SSI payments.

  1. Description of Collection

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.

  1. Use of Information Technology to Collect the Information

This form is available as a print-only, fillable PDF on SSA’s website. This collection does not currently have a fully public facing Internet version, as we prioritized other information collections for full electronic conversions. Given that IT Mod programming is an ongoing, dynamic project, we cannot provide specific timelines for when we will be able to make any particular ICR available via Internet web-based application. We will ultimately convert most existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this may be unconnected to the PRA approval lifecycle.

In the interim, we evaluated this collection for conversion to a submittable PDF. Given the high volume of conversions we are coordinating and the more urgent nature of some of the other conversions, we ultimately decided not to prioritize this ICR for conversion to fully submittable PDF at this time. When we are able to schedule this form for conversion to a submittable PDF, we will submit a Change Request to OMB to request prior approval.

  1. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.

  1. Minimizing Burden on Small Respondents

This collection does affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently If we did not use Form SSA-6233-BK, we would have no way of knowing if the payee knowingly made any unauthorized expenditures, constituting a “misapplication” of funds, and we would not know if they are recoverable from the payee on a dollar-for-dollar basis. Because we collect this information annually to avoid fraud and unauthorized expenditures, we cannot collect it less frequently. There are no technical or legal obstacles that prevent burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

  1. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on August 23, 2021 at 86 FR 47190, and we received no public comments.  The 30-day FRN published on November 18, 2021 at 86 FR 64585.  If we receive any comments in response to this Notice, we will forward them to OMB.

  1. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

  1. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

  1. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

  1. Estimates of Public Reporting Burden

Please see the burden chart below:

Modality of Completion

Number of Respondents

Frequency of Response

Average Burden Per Response (minutes)

Estimated Total Annual Burden (hours)

Average Theoretical Hourly Cost Amount (dollars)*

Average Wait Time in Field Office or for Teleservice Centers

(minutes) **

Total Annual Opportunity Cost (dollars)***









* We based this figure on the average U.S. worker’s hourly wages, as reported by Bureau of Labor Statistics data (

** We based this figure on averaging both the average FY 2021 wait times for field offices and teleservice centers, based on SSA’s current management information data.

*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

In addition, OMB’s Office of Information and Regulatory Affairs (OIRA) is requiring SSA to use a rough estimate of a 30-minute, one-way, drive time in our calculations of the time burden for this collection. OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97-mile driving distance for one-way travel. We depict this on the chart below:

Total Number of Respondents Who Visit a Field Office

Frequency of Response

Average One-Way Travel Time to a Field Office (minutes)

Estimated Total Travel Time to a Field Office (hours)

Total Annual Opportunity Cost for Travel Time (dollars)****






**** We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

Per OIRA, we include this travel time burden estimate under the 5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.” SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data which shows that the average respondent drives to a field office, rather than using any other mode of transport. SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.

NOTE: We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.

The total burden for this ICR is 10,500 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $1,009,035. SSA does not charge respondents to complete our applications. We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection. Per our management information data, we believe that the 20 minutes accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions. Based on our current management information data, the current burden information we provided is accurate.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

  1. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $386,495. This estimate accounts for costs from the following areas:

Description of Cost Factor

Methodology for Estimating Cost

Cost in Dollars*

Designing and Printing the Form

Design Cost + Printing Cost


Distributing, Shipping, and Material Costs for the Form

Distribution + Shipping + Material Cost


SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time

GS-9 employee x # of responses x processing time


Full-Time Equivalent Costs

Out of pocket costs + Other expenses for providing this service


Systems Development, Updating, and Maintenance

GS-9 employee x man hours for development, updating, maintenance


Quantifiable IT Costs

Any additional IT costs




* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have.  It is difficult for us to break down the cost for processing a single form, as field office staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection Request

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.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

  1. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

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File TitleTitle of Information Collection and Form Number(s)
File Modified0000-00-00
File Created2021-11-27

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