Information Collection

Representative Payee Evaluation Report--State/Local Government

IC 181091 under ICR 202603-0960-018 · OMB 0960-0069.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-624-F5 Representative Payee Evaluation Report Representative Payee Evaluation Report--State/Local Government	Form
Privacy Act Statement (revised).docx	Other-Revised PA Statement
SSA-624-F5 Representative Payee Evaluation Report SSA-624-F5 (revised).pdf	Form
SSA-624-F5 (current).pdf SSA-624-F5 - Current	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 404.2062 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	SSA-624-F5				Yes	No	Fillable Printable
Other-Revised PA Statement					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: 38

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
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	38	0	38
Annual IC Time Burden (Hours)	68	15	53
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-624-F5 - Current		04/13/2026

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

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