Information Collection

Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665

IC 9534 under ICR 202406-0960-002 · OMB 0960-0576.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0576 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-6233-BK Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665	Form and Instruction
Privacy Act Statement 0960-0576 (revised).docx	Other-Revised Privacy Act Statements
Privacy Act Statement 0960-0576 (revised).docx	Other-Revised Privacy Act Statements
SSA-6233-BK Representative Payee Report of Benefits and Dedicated Ac SSA-6233 (revised).pdf	Form and Instruction
SSA-6233-BK Representative Payee Report of Benefits and Dedicated Ac SSA-6233 (revised).pdf	Form and Instruction
SSA-6233 (current).pdf SSA-6233-BK - Current	IC Document
SSA-6233 (current).pdf SSA-6233-BK - Current	IC Document

IC Title:

Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665

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 416.546 20 CFR 416.640 20 CFR 416.635 20 CFR 416.665

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 and Instruction	SSA-6233-BK	Representative Payee Report of Benefits and Dedicated Account	SSA-6233 (revised).pdf		Yes	No	Fillable Printable
Other-Revised Privacy Act Statements			Privacy Act Statement 0960-0576 (revised).docx		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: 6,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	6,800	-24,700	31,500
Annual IC Time Burden (Hours)	1,700	-8,800	10,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-6233-BK - Current	SSA-6233 (current).pdf	06/07/2024

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