3220-0052

OMB NO. 3220-0052

Justification

Application to Act as Representative Payee

RRB Forms AA-5, G-478 and RB-5

1. Circumstances of information collection - Under Section 12 of the Railroad Retirement Act, the Railroad Retirement Board (RRB) may pay benefits to a representative payee when an employee, spouse or survivor annuitant is incompetent or is a minor. A representative payee may be a court-appointed guardian, a statutory conservator or an individual selected by the RRB. The procedures pertaining to the appointment and responsibilities of a representative payee are prescribed in 20 CFR 266.

2. Purposes of collecting/consequences of not collecting the information - The forms and the means supplied by the RRB for use in applying for representative payee status, for furnishing the information needed to support the application, and for maintaining the required records are as follows:

RRB Form AA-5, Application for Substitution of Payee, obtains information needed for selection of a representative payee who will serve in the best interest of the beneficiary be it an individual or institution (primarily nursing home). The form can be requested from any RRB field office in person, by telephone or by mail. Before releasing Form AA-5, the field office enters the RRB claim number, the employee's SS number and name, the beneficiary's name and the field office number. The completed form is returned to the RRB field office in person or by mail.

The RRB proposes no changes to Form AA-5.

AA-5 is similar to Form SSA-11-BK, Request to be Selected as Payee, OMB No. 0960-0014.

RRB Form G-478, Statement Regarding Patient's Capability to Manage Payments, obtains information about an annuitant's capability to manage payments. The form is completed by the annuitant's personal physician or by a medical officer, if the annuitant is in an institution.

A Form G-478 is not required when a court has appointed an individual or institution to manage the annuitant's funds. The form is also not required when the annuitant is a minor.

Before releasing Form G-478, the responsible RRB field office enters the physician's or medical officer's name and address, the RRB claim number, the name of the railroad employee, the name of the beneficiary, the field office address and the name and telephone number of the office representative.

The RRB proposes no changes to Form G-478.

The RRB also supplies representative payees (individuals or institutions) with a booklet at the time of their appointment. The booklet, RRB Form RB-5, Your Duties as Representative Payee-Representative Payee's Record, advises representative payees of their responsibilities under 20 CFR 266.9 and provides a means for the representative payee to maintain records pertaining to the receipt and use of RRB benefits. (This booklet is provided for the representative payee's convenience. The RRB also accepts records that are kept by representative payees as part of common business practices.)

The RRB proposes no changes to Form RB-5.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction – Not practicable: Form AA-5 requires an interview and the form is initiated by RRB with pre-filled data. It is also part of a larger process that will not be automated (Form G-478).

4. Efforts to identify duplication - This information collection does not duplicate any other data collection.

5. Small business respondents - N.A.

6. Consequences of less frequent collection - Not applicable since the information is requested only once for each representative payee selection.

7. Special circumstances - None

8. Public comments/consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on page 16875 and 16876 of the April 2, 2010 Federal Register. No comments were received.

9. Payments or gifts to respondents - None

10. Confidentiality - Privacy Act System of Records, RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System - RRB.

11. Sensitive questions - N.A.

12. Estimate of respondent burden - Our estimated annual burden for the information collection remains unchanged and is as follows:

Form #	Responses	Time (Min)	Burden (Hours)
AA-5** (individuals) (institutions)	3,000 2,250 750	17	850 637.5 212.5
G-478	2,000	6	200
RB-5** (individuals) (institutions)	15,300 11,475 3,825	*60	15,300 11,475 3,825
Total	20,300		16,350

* Based on recordkeeping of 5 minutes per month for a total of 1 hour per year.

**Broken into two separate IC’s based on two types of respondents.

• Individuals

• Institutions/Nursing Homes

13. Estimated annual cost to respondents or record keepers - N.A.

14. Estimate of cost to Federal Government - N.A.

15. Explanation for change in burden – N.A.

16. Time schedule for data collection and publication - The results of this collection will not be published.

17. Request not to display OMB expiration date - The public-use forms included with this collection are seldom revised. Given the costs associated with the redrafting, reprinting and distributing the forms in order to display the current OMB expiration date, the RRB requests that OMB not require the RRB to display the OMB expiration date on the forms.

18. Exceptions to Certification Statement - None

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