Information Collection

Application to Collect A Fee for Payee Services (State/local government offices)

IC 9776 under ICR 202405-0960-004 · OMB 0960-0719.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-445 Application to Collect A Fee for Payee Services (State/local government offices)	Form
SSA-445 Application to Collect a Fee for Payee Services (State/l SSA-445 - Revised.pdf	Form
SSA-445 Application to Collect a Fee for Payee Services (State/l SSA-445 - Revised.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.640(a) 20 CFR 404.2040(a)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-445	Application to Collect a Fee for Payee Services (State/local government)	SSA-445 - Revised.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10	0	10
Annual IC Time Burden (Hours)	5	3	2
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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