STATEMENT OF CARE AND RESPONSIBILITY FOR BENEFICIARY

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
114709	STATEMENT OF CARE AND RESPONSIBILITY FOR BENEFICIARY Form	Migrated

ICR Details

OMB Control No: 0960-0109	ICR Reference No: 199207-0960-006
Status: Historical Active	Previous ICR Reference No: 199006-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: STATEMENT OF CARE AND RESPONSIBILITY FOR BENEFICIARY
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: 10/03/1992
	Date Received in OIRA: 07/24/1992
Terms of Clearance: This information collection is approved through 4-94 under the following conditions: SSA should consider updating this form and making it more user-friendly for the repsondent. For example, SSA should enhance the instructions and put them on the back of the fo or on a separate sheet instead of on the form itelf. This will allow for more room on the form to provide adequate space for the answers. In it's present form, the space for the answers is still insufficient unless the respondent is typing the answers. In addition, please justify why SSA needs the name and address of the individual that plac the beneficiary with the custodian (1.a), and the name and address of any individual that performs tasks for the beneficiary (3.b).

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/1994	04/30/1994	08/31/1992
Responses	130,000	0	130,000
Time Burden (Hours)	21,667	0	21,667
Cost Burden (Dollars)	0	0	0

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Abstract: THE INFORMATION COLLECTED BY FORM SSA-788 IS USED BY THE SOCIAL SECURITY ADMINISTRATION TO EVALUATE THE CONCERN THAT A POTENTIAL PAYEE SHOWS TOWARD THE BENEFICIARY. THE AFFECTED PUBLIC CONSISTS OF INDIVIDUALS OR INSTITUTIONS WHO HAVE CUSTODY OF BENEFICIARY FOR WHOM SOMEONE ELSE HAS FILED TO BE REPRESENTATIVE PAYEE.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

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
STATEMENT OF CARE AND RESPONSIBILITY FOR BENEFICIARY	SSA-788

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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	130,000	130,000	0	0	0	0
Annual Time Burden (Hours)	21,667	21,667	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:

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Annual Cost to Federal Government: $0

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

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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: 07/24/1992

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