Information Collection

Representative Payee Evaluation Report--Private Sector

IC 181092 under ICR 202204-0960-005 · OMB 0960-0069.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0069 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-624-F5 Representative Payee Evaluation Report--Private Sector Form
Revised PA & PRA Statements.pdf Other-Revised PA & PRA Statements
Revised PA & PRA Statements.pdf Other-Revised PA & PRA Statements
SSA-624-F5 Representative Payee Evaluation Report SSA-624-F5 - Revised.pdf Form
SSA-624-F5 Representative Payee Evaluation Report SSA-624-F5 - Revised.pdf Form
SSA-624-F5 - Current.pdf SSA-624-F5 - Current IC Document
SSA-624-F5 - Current.pdf SSA-624-F5 - Current IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Representative Payee Evaluation Report--Private Sector	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 404.2065 20 CFR 416.665

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-624-F5	Representative Payee Evaluation Report	SSA-624-F5 - Revised.pdf		Yes	No	Fillable Printable
Other-Revised PA & 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: 263	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Farms, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	263	-17	280
Annual IC Time Burden (Hours)	368	228	140
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-624-F5 - Current	SSA-624-F5 - Current.pdf	08/25/2022

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