Addendum to the Supporting Statement

Addendum to

Supporting Statement for form SSA-445

Application To Collect A Fee For Payee Services

20 CFR 404.2040a, 416.640a

OMB No. 0960-0719

Revisions to the Collection Instrument

We are revising form SSA-445 (Application To Collect A Fee For Payee Services) for clarification and to streamline processing. The revision of form SSA-445 will help field offices when authorizing fee-for-service payee applicants. We will request the field offices to stop using the old forms, destroy them, and start using the new stock immediately after OMB approval.

Change 1: We are deleting the word “Our” in the second bullet at the top of the SSA-445.

• Old Language: Our organization’s mission statement

• New Language: Organization’s Mission Statement

Justification 1: The word “Our” is not relevant to the question.

Change 2: We are adding two bullets at the top of the form.

• Proof of State license (if applicable)

• Proof of bond/insurance (if applicable)

Justification 2: We are adding this language to clarify the statutorily required requirements for authorization to collect a fee for payee services.

Change 3: We are revising questions 4 and 5.

Question 4:

• Old Language: Address, City State, Zip Code

• New Language: Mailing Address, City State, Zip Code

Question 5:

• Old Language: City, State, Zip Code

• New Language: Location Address, City, State, and Zip Code

Justification 3: We are changing this language to capture both a mailing address and a location address because this information is essential in the authorization and subsequent monitoring process for fee for service payees.

Change 4: We are removing questions 8, 9 and 10.

Justification 4: The information these questions solicit is not relevant to the organization’s approval to collect a fee for payee services.

Change 5: Addition of new question 8 asking: “Does the bond/policy coverage include claims against all officers and employees for theft? Yes___No___.”

Justification 5: The information this question solicits is necessary to ensure compliance with regulatory requirements.

Change 6: Addition of new question 9 asking: “Does your organization receive or collect money from other sources for representative payee services? Yes__ No__If yes, amount____.”

Justification 6: The information this question solicits is necessary to ensure compliance with regulatory requirements governing the amount of fees an organization may collect.

Change 7: Renumbering of question 11 to question 10 and revision to language in existing question to ask, “Does your organization serve as representative payee in multiple areas? Yes___No___If yes, list all the locations (branches) including mailing addresses and contact information.

Justification 7: This information this question solicits is necessary to identify other branches of the organization that may require authorization to collect a fee for payee services.