Request to be Selected as a Payee

Forms and Documents

Document Name	Status
Form SSA-11-BK Individuals/Households: Paper SSA-11-BK Form	Modified
Form SSA-11-BK State/Local/Tribal Government: Paper SSA-11-BK Form	Modified
Form SSA-11-BK Private Sector: Paper SSA-11-BK Form	Modified
Supporting Statement - 0014 (Final).docx Supporting Statement A	2022-06-02

IC Document Collections

IC ID	Document Title	Status
8897	Individuals/Households: Paper SSA-11-BK Form	Modified
44953	Individuals/Households: Representative Payee System (RPS) Other-Internal Use Screens	Modified
186315	State/Local/Tribal Government: RPS Other-Internal Use Screens	Modified
186313	State/Local/Tribal Government: Paper SSA-11-BK Form	Modified
186312	Private Sector: RPS Other-Internal Screens	Modified
186310	Private Sector: Paper SSA-11-BK Form	Modified

ICR Details

OMB Control No: 0960-0014	ICR Reference No: 202203-0960-007
Status: Received in OIRA	Previous ICR Reference No: 201812-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Request to be Selected as a Payee
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/02/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2022
Responses	2,034,847	1,975,580
Time Burden (Hours)	2,070,420	395,116
Cost Burden (Dollars)	0	0

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Abstract: SSA requires individuals applying to be representative payees for OASDI, or SSI recipients to complete Form SSA-11-BK or, supply the same information to a field office technician through a personal interview. SSA obtains information from applicant payees regarding their relationship to the recipient; personal qualifications; concerns for the recipient’s well-being; and intended use of payments if appointed as payee. SSA collects this on paper Form SSA-11-BK, or through eRPS, an electronic version of the form, which field office technicians complete during a face-to-face interview with the applicant. The respondents are individuals; private sector businesses and institutions; and State and local government institutions and agencies applying to become representative payees.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
   PL: Pub.L. 108 - 203 103 & 203 Name of Law: Social Security Protection Act of 2004
   PL: Pub.L. 115 - 165 103(a) & 104 Name of Law: Strengthening Protections for Social Security Act of 2018
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 203 103 & 203 Name of Law: Social Security Protection Act of 2004
PL: Pub.L. 115 - 165 103(a) & 104 Name of Law: Strengthening Protections for Social Security Act of 2018

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 18456	03/30/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 33282	06/01/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

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

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ICR Summary of Burden

	Total Request	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	2,034,847	1,975,580	0	0	59,267	0
Annual Time Burden (Hours)	2,070,420	395,116	0	0	1,675,304	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: When we last cleared this IC in 2018 the burden was 395,116 hours. However, we are currently reporting a burden of 406,969. This change stems from the increase in the number of responses from 1,975,580 to 2,034,847. There is no change to the burden time per response. *Note: The total burden reflected in ROCIS is 2,070,420, while the burden cited in #12 above is 406,969. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + telephone call system wait times + a rough estimate of a 30-minute, one-way, drive burden. In contrast, the chart in #12 above reflects actual burden.

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Annual Cost to Federal Government: $8,989,304

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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: 06/02/2022

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