Information Collection Request
Application to Act as Representative Payee
ICR 202303-3220-001 · OMB 3220-0052 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 3220-0052 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form AA-5 Application for Substitution of Payee and Duties As Representative Payee (Individuals) |
Form | Modified | Repair queued |
| Form G-478 Statement Regarding Patient's Capability to Manage Payments |
Form and Instruction | Modified | Repair queued |
| 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
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 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 | |
| 179617 | Application for Substitution of Payee and Duties as Representative Payee (Institutions) |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | RRB |
| OMB Control No | 3220-0052 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 201912-3220-003 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |