Application to Collect A Fee for Payee Services (State/local government offices)

Application to Collect A Fee for Payee Services

Documents and Forms

Document Name Document Type
Form SSA-445 Application to Collect A Fee for Payee Services (State/local government offices) Form
SSA-445 Application to Collect a Fee for Payee Services (State/l SSA-445 - Revised.pdf Form
SSA-445 Application to Collect a Fee for Payee Services (State/l SSA-445 - Revised.pdf Form

Information Collection (IC) Details

IC Title:	Application to Collect A Fee for Payee Services (State/local government offices)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.640(a) 20 CFR 404.2040(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-445	Application to Collect a Fee for Payee Services (State/local government)	SSA-445 - Revised.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10	0	10
Annual IC Time Burden (Hours)	5	3	2
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.