Information Collection

Representative Payee Report of Benefits and Dedicated Account

IC 9534 under ICR 202408-0960-004 · OMB 0960-0576.

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	Form and Instruction
SSA-6233-BK Representative Payee Report of Benefits and Dedicated Ac SSA-6233.pdf www.ssa.gov	Form and Instruction

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 416.546 20 CFR 416.635 20 CFR 416.640 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.pdf	www.ssa.gov	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
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,800	0	6,800
Annual IC Time Burden (Hours)	5,213	3,513	1,700
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.