Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665

Representative Payee Report of Benefits and Dedicated Account

Documents and Forms

Document Name Document Type
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
Revised PA & PRA Statements.pdf Other-Revised PA and PRA Statements
Revised PA & PRA Statements.pdf Other-Revised PA and PRA Statements
SSA-6233-BK Representative Payee Report of Benefits and Dedicated Ac SSA-6233-BK - Revised.pdf Form and Instruction
SSA-6233-BK Representative Payee Report of Benefits and Dedicated Ac SSA-6233-BK - Revised.pdf Form and Instruction
SSA-6233-BK - Current.pdf SSA-6233-BK - Current IC Document
SSA-6233-BK - Current.pdf SSA-6233-BK - Current IC Document

Information Collection (IC) Details

IC Title:	Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.546 20 CFR 416.640 20 CFR 416.665 20 CFR 416.635

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-6233-BK	Representative Payee Report of Benefits and Dedicated Account	SSA-6233-BK - Revised.pdf		Yes	No	Fillable Printable
Other-Revised PA and PRA Statements			Revised PA & PRA Statements.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 31,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	31,500	-4,728	36,228
Annual IC Time Burden (Hours)	10,500	-1,576	12,076
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-6233-BK - Current	SSA-6233-BK - Current.pdf	11/01/2021

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