Application to Act as Representative Payee

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form RB-5 (xx-xx) RB-5 Booklet: Your Duties as Representative Payee - Representative Payee's Record	Form and Instruction	Modified	Available
Form AA-5 (xx-xx) Application for Substitution of Payee	Form	Modified	Available
Form RB-5 RB-5 Booklet; Your Duties as Representative Payee - Representative Payee's Record	Form and Instruction	Modified	Available
Form AA-5 Application for Substitution of Payee	Form	Modified	Available
Form AA-5 Application for Substitution of Payee and Duties As Representative Payee (Individuals)	Form	Modified	Repair queued
Form G-478 (xx-xx) Statement Regarding Patient's Capability to Manage Payments	Form and Instruction	Modified	Available
Form G-478 Statement Regarding Patient's Capability to Manage Payments	Form and Instruction	Modified	Available
Form G-478 Statement Regarding Patient's Capability to Manage Payments	Form and Instruction	Modified	Repair queued
Form RB-5 (xx-xx) Your Duties as Representative Payee - Representative's Payee's Record	Form and Instruction	Modified	Available
Form AA-5 (xx-xx) Application for Substitution of Payee	Form and Instruction	Modified	Available
Form RB-5 Your Duties as Representative Payee-Representative's Payee's Record	Form and Instruction	Modified	Available
Form AA-5 Application for Substitution of Payee	Form and Instruction	Modified	Available
Form AA-5 Application for Substitution of Payee and Duties as Representative Payee (Institutions)	Form and Instruction	Modified	Repair queued
3220-0052.docx	Supporting Statement A	Uploaded 2023-03-28	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33865	Application for Substitution of Payee and Duties As Representative Payee (Individuals)	Form and Instruction	Modified	RB-5 Booklet: Your Duties as Representative Payee - Representative Payee's Record
33865	Application for Substitution of Payee and Duties As Representative Payee (Individuals)	Form	Modified	Application for Substitution of Payee
33865	Application for Substitution of Payee and Duties As Representative Payee (Individuals)	Form and Instruction	Modified	RB-5 Booklet; Your Duties as Representative Payee - Representative Payee's Record
33865	Application for Substitution of Payee and Duties As Representative Payee (Individuals)	Form	Modified	Application for Substitution of Payee
33865	Application for Substitution of Payee and Duties As Representative Payee (Individuals)	Form	Modified
179885	Statement Regarding Patient's Capability to Manage Payments	Form and Instruction	Modified	Statement Regarding Patient's Capability to Manage Payments
179885	Statement Regarding Patient's Capability to Manage Payments	Form and Instruction	Modified	Statement Regarding Patient's Capability to Manage Payments
179885	Statement Regarding Patient's Capability to Manage Payments	Form and Instruction	Modified
179617	Application for Substitution of Payee and Duties as Representative Payee (Institutions)	Form and Instruction	Modified	Your Duties as Representative Payee - Representative's Payee's Record
179617	Application for Substitution of Payee and Duties as Representative Payee (Institutions)	Form and Instruction	Modified	Application for Substitution of Payee
179617	Application for Substitution of Payee and Duties as Representative Payee (Institutions)	Form and Instruction	Modified	Your Duties as Representative Payee-Representative's Payee's Record
179617	Application for Substitution of Payee and Duties as Representative Payee (Institutions)	Form and Instruction	Modified	Application for Substitution of Payee
179617	Application for Substitution of Payee and Duties as Representative Payee (Institutions)	Form and Instruction	Modified

ICR Details

OMB Control No: 3220-0052	ICR Reference No: 202303-3220-001
Status: Active	Previous ICR Reference No: 201912-3220-003
Agency/Subagency: RRB	Agency Tracking No:
Title: Application to Act as Representative Payee
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: 06/11/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/28/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2026	36 Months From Approved	06/30/2023
Responses	20,300	0	20,300
Time Burden (Hours)	16,350	0	16,350
Cost Burden (Dollars)	0	0	0

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Abstract: Under Section 12 of the Railroad Retirement Act, the Railroad Retirement Board (RRB) may pay benefits to a representative payee when an employee, spouse or survivor annuitant is incompetent or is a minor. The collection obtains information related to the representative payee application, supporting documentation and the maintenance of records pertaining to the receipt and use of benefits.

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Authorizing Statute(s): US Code: 45 USC 231k Name of Law: Railroad Retirement Act
   US Code: 45 USC 231f Name of Law: Railroad Retirement Act
  

Citations for New Statutory Requirements: None

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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:
	88 FR 4223	01/24/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 18189	03/27/2023
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
Application for Substitution of Payee and Duties As Representative Payee (Individuals)	AA-5, RB-5, AA-5 (xx-xx), RB-5 (xx-xx)	Application for Substitution of Payee ,   RB-5 Booklet; Your Duties as Representative Payee - Representative Payee's Record ,   Application for Substitution of Payee ,   RB-5 Booklet: Your Duties as Representative Payee - Representative Payee's Record
Application for Substitution of Payee and Duties as Representative Payee (Institutions)	AA-5, RB-5, AA-5 (xx-xx), RB-5 (xx-xx)	Application for Substitution of Payee ,   Your Duties as Representative Payee-Representative's Payee's Record ,   Application for Substitution of Payee ,   Your Duties as Representative Payee - Representative's Payee's Record
Statement Regarding Patient's Capability to Manage Payments	G-478, G-478 (xx-xx)	Statement Regarding Patient's Capability to Manage Payments ,   Statement Regarding Patient's Capability to Manage Payments

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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	20,300	20,300	0	0	0	0
Annual Time Burden (Hours)	16,350	16,350	0	0	0	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:

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Annual Cost to Federal Government: $0

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: 03/28/2023

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