Information Collection

Application to Collect A Fee for Payee Services

IC 9776 under ICR 201109-0960-014 · OMB 0960-0719.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0719 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-445 Application to Collect A Fee for Payee Services Form
SSA-445 Application to Collect a Fee for Payee Services (State/l MOCK UP SSA-445 (revised).pdf Form
SSA-445 (current).pdf SSA-445 (current) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application to Collect A Fee for Payee Services	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)	MOCK UP 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	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-445 (current)	SSA-445 (current).pdf	10/14/2011

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