Information Collection

Representative Payee Evaluation Report--Private Sector

IC 181092 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--Private Sector	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 416.665 20 CFR 404.2065

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: 260

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Farms, Businesses or other for-profits

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	260	-3	263
Annual IC Time Burden (Hours)	468	100	368
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].