Representative Payee Evaluation Report

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-624-F5 Representative Payee Evaluation Report	Form	Modified	Available
Form SSA-624-F5 Representative Payee Evaluation Report--Individuals/Households	Form	Modified	Repair queued
Form SSA-624-F5 Representative Payee Evaluation Report	Form	Modified	Available
Form SSA-624-F5 Representative Payee Evaluation Report--Private Sector	Form	Modified	Repair queued
Form SSA-624-F5 Representative Payee Evaluation Report	Form	Modified	Available
Form SSA-624-F5 Representative Payee Evaluation Report--State/Local Government	Form	Modified	Repair queued
Addendum - 0069 (Final).docx	Supplementary Document	Uploaded 2022-09-20	Repair queued
Supporting Statement - 0069 (Final).docx	Supporting Statement A	Uploaded 2022-10-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9009	Representative Payee Evaluation Report--Individuals/Households	Form	Modified	Representative Payee Evaluation Report
9009	Representative Payee Evaluation Report--Individuals/Households	Form	Modified
9009	Representative Payee Evaluation Report--Individuals/Households	Other-Revised PA & PRA Statements	Modified
181092	Representative Payee Evaluation Report--Private Sector	Form	Modified	Representative Payee Evaluation Report
181092	Representative Payee Evaluation Report--Private Sector	Form	Modified
181092	Representative Payee Evaluation Report--Private Sector	Other-Revised PA & PRA Statements	Modified
181091	Representative Payee Evaluation Report--State/Local Government	Form	Modified	Representative Payee Evaluation Report
181091	Representative Payee Evaluation Report--State/Local Government	Form	Modified
181091	Representative Payee Evaluation Report--State/Local Government	Other-Revised PA & PRA Statements	Modified

ICR Details

OMB Control No: 0960-0069	ICR Reference No: 202204-0960-005
Status: Active	Previous ICR Reference No: 201904-0960-003
Agency/Subagency: SSA	Agency Tracking No:
Title: Representative Payee Evaluation Report
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: 04/19/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/03/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2026	36 Months From Approved	04/30/2023
Responses	6,838	0	7,276
Time Burden (Hours)	9,246	0	3,638
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the Representative Payee Evaluation Report, Form SSA-624-F5, as a documentation tool for interviews with, and evaluations of, representative payees. SSA requires our field offices (FO) to conduct a face-to-face interview with the representative payee using Form SSA-624-F5 when: (1) SSA finds the payee’s responses on SSA-required annual accounting reports [Forms SSA-623, SSA 6230, and SSA-6234 (OMB No. 0960 0068)] unacceptable, and we cannot resolve them; (2) the payee fails to complete SSA’s initial and second request for an annual accounting report; or (3) assessing the representative payee’s continued suitability. In addition to the representative payee, we also interview the beneficiary or SSI recipient, and custodian (if other than the payee) to confirm information the payee provides, and to ensure the payee is meeting the beneficiary’s or SSI recipient’s current needs (face to-face interview not required). The respondents are individuals or organizations serving as representative payees for individuals receiving Title II benefits or Title XVI payments who fail to comply with SSA’s statutory annual reporting requirement, SSA beneficiaries or recipients, and third-party custodians.

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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
  

Citations for New Statutory Requirements: PL: Pub.L. 115 - 165 102 Name of Law: Strengthening Protections for Social Security Benefits Act of 2018

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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:
	87 FR 39153	06/30/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 57551	09/20/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Representative Payee Evaluation Report--Individuals/Households	SSA-624-F5	Representative Payee Evaluation Report
Representative Payee Evaluation Report--Private Sector	SSA-624-F5	Representative Payee Evaluation Report
Representative Payee Evaluation Report--State/Local Government	SSA-624-F5	Representative Payee Evaluation Report

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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	6,838	7,276	0	0	-438	0
Annual Time Burden (Hours)	9,246	3,638	0	0	5,608	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 2019, the burden was 3,638 hours. However, we are currently reporting a burden of 3,420 hours. This change stems from a decrease in the number of responses from 7,276 to 6,838. 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. Note: The total burden reflected in ROCIS is 9,246, while the burden cited in #12 of the Supporting Statement is 3,420. This discrepancy is because the ROCIS burden reflects the following components: field office and teleservice center waiting times + a rough estimate of a 30-minute, one-way, drive burden. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

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Annual Cost to Federal Government: $116,657

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: 10/03/2022

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