Statement of Care and Responsibility for Beneficiary

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-788 Statement of Care and Responsibility for Beneficiary	Form	Modified	Available
Form SSA-788 Statement of Care and Responsibility for Beneficiary	Form	Modified	Repair queued
Addendum 0109.docx	Supplementary Document	Uploaded 2021-08-24	Available
Addendum 0109.docx	Supplementary Document	Uploaded 2021-08-24	Repair queued
Supporting Statement - 0109 (Final).docx	Supporting Statement A	Uploaded 2024-07-23	Available
Supporting Statement - 0109 (Final).docx	Supporting Statement A	Uploaded 2021-09-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43697	Statement of Care and Responsibility for Beneficiary	Form	Modified	Statement of Care and Responsibility for Beneficiary
43697	Statement of Care and Responsibility for Beneficiary	Form	Modified
43697	Statement of Care and Responsibility for Beneficiary	Other-Paper Reduction Act Statement revised	Modified

ICR Details

OMB Control No: 0960-0109	ICR Reference No: 202108-0960-011
Status: Active	Previous ICR Reference No: 201803-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of Care and Responsibility for Beneficiary
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/12/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/03/2021
Terms of Clearance: The agency made minor modifications to the Supporting Statement to clarify how it is used and updated the respondent count. Prior to triannual renewal, the agency will evaluate this information collection for electronic submission consistent with the agency's commitments under Sec. 4 (k)(iii) and (iv) of E.O. 14058.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2027	36 Months From Approved	08/31/2024
Responses	134,000	0	130,000
Time Burden (Hours)	22,333	0	21,667
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA uses the information from Form SSA-788 to verify payee applicants' statements of concern and to identify other potential payees. SSA is concerned with selecting the most qualified representative payee who will use Social Security benefits in the beneficiary's best interest. SSA considers factors such as the payee applicant's capacity to perform payee duties, awareness of the beneficiary's situation and needs, demonstration of past and current concern for the beneficiary's well-being, etc. If the payee applicant does not have custody of the beneficiary, SSA will obtain information from the custodian for evaluation against information provided by the applicant. Respondents are individuals who have custody of the beneficiary in cases where someone else has filed to be the beneficiary's representative payee. Form SSA-788 is an agency generated form, which SSA completes the top portion of Form SSA-788, sends to the custodians of the beneficiaries, and they complete the rest of the form and gives back to us.

---

Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 1007 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 35371	07/02/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 49403	09/02/2021
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Statement of Care and Responsibility for Beneficiary	SSA-788	Statement of Care and Responsibility for Beneficiary

---

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	134,000	130,000	0	0	4,000	0
Annual Time Burden (Hours)	22,333	21,667	0	0	666	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 21,667 hours. However, we are currently reporting a burden of 22,333 hours. This change stems an increase in the number of responses from 130,000 to 134,000. 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.

---

Annual Cost to Federal Government: $494,620

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

---

Common Form ICR:  No

---

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: 09/03/2021

---