Representative Payee Evaluation Report

Forms and Documents

Document Name	Status
Form SSA-624-F5 Representative Payee Evaluation Report--Individuals/Households Form	Modified
Form SSA-624-F5 Representative Payee Evaluation Report--Private Sector Form	Modified
Form SSA-624-F5 Representative Payee Evaluation Report--State/Local Government Form	Modified
Addendum - 0069.doc Supplementary Document	2016-06-20
Supporting Statement - 0069.docx Supporting Statement A	2016-07-04

IC Document Collections

IC ID	Document Title	Status
9009	Representative Payee Evaluation Report--Individuals/Households Form	Modified
181092	Representative Payee Evaluation Report--Private Sector Form	Modified
181091	Representative Payee Evaluation Report--State/Local Government Form	Modified

ICR Details

OMB Control No: 0960-0069	ICR Reference No: 201603-0960-003
Status: Historical Active	Previous ICR Reference No: 201305-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Representative Payee Evaluation Report
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/17/2016
	Date Received in OIRA: 07/04/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved	08/31/2016
Responses	267,000	0	267,000
Time Burden (Hours)	133,500	0	133,500
Cost Burden (Dollars)	0	0	0

---

Abstract: Sections 205(j) and 1631(a)(2) of the Social Security Act state SSA may appoint a representative payee to receive benefits on behalf of an individual entitled to title II benefits and/or title XVI payments when that individual is unable to manage or direct the management of those funds themselves. SSA requires representative payees to report to SSA at least once per year on how they used or conserved those funds. When a representative payee fails to adequately report to SSA as required, SSA conducts a face-to-face interview with the payee and completes an SSA-624, Representative Payee Evaluation Report, to determine the continued suitability of the representative payee to serve as a payee. The respondents are individuals and organizations serving as representative payees for title II and title XVI recipients who fail to comply with SSA's statutory annual reporting requirement.

---

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
  

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:
	81 FR 15774	03/24/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 39990	06/20/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Representative Payee Evaluation Report--Individuals/Households	SSA-624-F5	Representative Payee Evaluation Report
Representative Payee Evaluation Report--Private Sector	SSA-624-F5	Representative Payee Evaluation Report
Representative Payee Evaluation Report--State/Local Government	SSA-624-F5	Representative Payee Evaluation Report

---

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	267,000	267,000	0	0	0	0
Annual Time Burden (Hours)	133,500	133,500	0	0	0	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:

---

Annual Cost to Federal Government: $1,754,190

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]? 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? 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: 07/04/2016

---