Representative Payee Report of Benefits and Dedicated Account

Forms and Documents

Document Name	Status
Form SSA-6233-BK Representative Payee Report of Benefits and Dedicated Account Form and Instruction	Modified
Supporting Statement - 0576 (Final).docx Supporting Statement A	2024-12-16

IC Document Collections

IC ID	Document Title	Status
9534	Representative Payee Report of Benefits and Dedicated Account Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0576	ICR Reference No: 202408-0960-004
Status: Received in OIRA	Previous ICR Reference No: 202406-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Representative Payee Report of Benefits and Dedicated Account
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 12/16/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2024
Responses	6,800	6,800
Time Burden (Hours)	5,213	1,700
Cost Burden (Dollars)	0	0

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Abstract: SSA requires payees to submit a written report accounting for the use of money paid to Social Security or Supplemental Security Income (SSI) recipients, and to establish and maintain a dedicated account for these payments. SSA uses Form SSA-6233-BK to: (1) Ensure the payee uses the payments for the recipient’s current maintenance and personal needs; and (2) confirm the expenditures of funds from the dedicated account remain in compliance with the law. Although we mail a paper Form SSA-6233-BK to the payee, the report can also be completed through telephone contact and then be mailed to the payee for signature, or during a face-to-face interview. The respondents are payees for SSI and Social Security recipients.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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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:
	89 FR 74351	09/12/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 88105	11/06/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Representative Payee Report of Benefits and Dedicated Account	SSA-6233-BK	Representative Payee Report of Benefits and Dedicated Account

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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	6,800	6,800	0	0	0	0
Annual Time Burden (Hours)	5,213	1,700	0	0	3,513	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: There are no changes to the public reporting burden. * Note: The total burden reflected in ROCIS is 5213, while the burden cited in #12 of the Supporting Statement is 17,000. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + learning costs. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

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Annual Cost to Federal Government: $488,515

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: 12/16/2024

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