Request to be Selected as Payee

Forms and Documents

Document Name	Status
Form SSA-11-BK Individuals/Households: Paper SSA-11-BK Form	Modified
Form SSA-11 RPS Screens Individuals/Households: Representative Payee System (RPS) Form	Modified
Form SSA-11 Representat Individuals/Households: Representative Payee System (RPS)/Signature Proxy Form	Modified
Form SSA-11 RPS Screens State/Local/Tribal Government: RPS Form	New
Form SSA-11 RPS Screens State/Local/Tribal Government: RPS/Signature Proxy Form	New
Form SSA-11-BK State/Local/Tribal Government: Paper SSA-11-BK Form	New
Form SSA-11 RPS Screens Private Sector: RPS Form	New
Form SSA-11 RPS Screens Private Sector: RPS/Signature Proxy Form	New
Form SSA-11-BK Private Sector: Paper SSA-11-BK Form	New
SSA-11-BK Mock-Up of Revisions--New Privacy Act Statements.pdf Supplementary Document	2009-03-13
Supporting Statement--0014.doc Supporting Statement A	2009-01-12
Addendum--0014.doc Supplementary Document	2008-12-30
SSA-11-BK -- Current Version.pdf Supplementary Document	2008-11-06

IC Document Collections

IC ID	Document Title	Status
8897	Individuals/Households: Paper SSA-11-BK Form	Modified
44953	Individuals/Households: Representative Payee System (RPS) Form	Modified
44950	Individuals/Households: Representative Payee System (RPS)/Signature Proxy Form	Modified
186315	State/Local/Tribal Government: RPS Form	New
186314	State/Local/Tribal Government: RPS/Signature Proxy Form	New
186313	State/Local/Tribal Government: Paper SSA-11-BK Form	New
186312	Private Sector: RPS Form	New
186311	Private Sector: RPS/Signature Proxy Form	New
186310	Private Sector: Paper SSA-11-BK Form	New

ICR Details

OMB Control No: 0960-0014	ICR Reference No: 200808-0960-009
Status: Historical Active	Previous ICR Reference No: 200805-0960-015
Agency/Subagency: SSA	Agency Tracking No:
Title: Request to be Selected as Payee
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/13/2009
	Date Received in OIRA: 01/12/2009
Terms of Clearance: Approved with the addition of a Privacy Act notice.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2012	36 Months From Approved	03/31/2009
Responses	1,500,000	0	1,500,000
Time Burden (Hours)	248,335	0	248,333
Cost Burden (Dollars)	0	0	0

---

Abstract: The information established by the form is necessary to determine the proper payee for a Social Security beneficiary. The form is designed to aid the investigation of a payee applicant. The use of the form will establish the applicant's relation to the beneficiary, his/her justification and his/her concern for the beneficiary, as well as the manner in which the benefits will be used. The respondents are applicants for selection as representative payee for Titles II, VIII, and XVI.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 53919	09/17/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 75490	12/11/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

IC Title	Form No.	Form Name
Private Sector: RPS/Signature Proxy	SSA-11 RPS Screens	Request to be Selected as Payee
State/Local/Tribal Government: Paper SSA-11-BK	SSA-11-BK	Request to be Selected as Payee
State/Local/Tribal Government: RPS	SSA-11 RPS Screens	Request to be Selected as Payee
Private Sector: Paper SSA-11-BK	SSA-11-BK	Request to be Selected as Payee
Individuals/Households: Representative Payee System (RPS)	SSA-11 RPS Screens	Request to be Selectred as Payee
Individuals/Households: Paper SSA-11-BK	SSA-11-BK	Request to be Selected as Payee
Individuals/Households: Representative Payee System (RPS)/Signature Proxy	SSA-11 Representative Payee System Screens	Request to be Selected as Payee
State/Local/Tribal Government: RPS/Signature Proxy	SSA-11 RPS Screens	Request to be Selected as Payee
Private Sector: RPS	SSA-11 RPS Screens	Request to be Selected as Payee

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,500,000	1,500,000	0	0	0	0
Annual Time Burden (Hours)	248,335	248,333	0	0	2	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The burden information for this form has not changed. Prior to ROCIS we were not able to show the various collection methods and respondent types individually. Therefore, we are now splitting them into individual ICs.

---

Annual Cost to Federal Government: $4,612,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/12/2009

---