Representative Payee Report of Benefits and Dedicated Account

Documents and Forms

Document Name Document Type
Form SSA-6233-BK Representative Payee Report of Benefits and Dedicated Account Form and Instruction
SSA-6233-BK Representative Payee Report of Benefits and Dedicated Ac SSA-6233.pdf www.ssa.gov Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Representative Payee Report of Benefits and Dedicated Account	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 416.546 20 CFR 416.635 20 CFR 416.640 20 CFR 416.665

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-6233-BK	Representative Payee Report of Benefits and Dedicated Account	SSA-6233.pdf	www.ssa.gov	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,800	0	6,800
Annual IC Time Burden (Hours)	5,213	3,513	1,700
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.