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 supplied by the RRB to an applicant for use in applying for representative payee status, for furnishing the information needed to support the application, and for maintaining the required account 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 completed in an RRB field office during an interview, which is preferable, or requested by telephone or by mail. Before releasing the form 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.

Completion of the form is self-explanatory.

The RRB proposes minor non-burden impacting editorial changes to Form AA-5:

• Items 3 and 5 - Revise the reference from “court appointed representative” to “court appointed legal guardian.”

• Page 7 - Update the agency’s business hours.

• Page 8 - Update the agency’s ZIP +4 at the end of the Paperwork Reduction Act.

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 Benefits, obtains information about the annuitant's capability to manage their own benefit payments. The form is usually completed by the annuitant’s physician. However, if the annuitant is in an institution, the form is completed by a medical officer.

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

Completion of the form is self-explanatory. Before releasing Form G-478, the RRB field office enters the physician's or medical officer's name, address, and telephone number; the railroad employee’s RRB Claim Number, Social Security Number and name; the beneficiary’s social security number and name; and the address and telephone number of the RRB office.

The physician or medical officer returns the completed form to the RRB office in the pre-addressed return envelope included for that purpose.

The RRB proposes minor non-burden impacting editorial changes to Form G-478.

• Update the agency’s ZIP +4 at the end of the RRB office return address and in the Paperwork Reduction Act.

• Item 9 - Revise “Physician’s Signature,” and “Physician’s Name,” to include the Medical Officer’s signature and name as well as title.

Form RB-5, Your Duties as Representative Payee-Representative Payee's Record, is a booklet supplied by the RRB to the representative payee (individual or institution) at the time of the appointment. The booklet describes the responsibilities of the representative payee under 20 CFR 266.9 and also contains a means to record the receipt and use of the annuitant’s 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 minor non-burden impacting editorial changes to Form RB-5.

• Front and back pages - Update the agency’s ZIP+4.

• Page 1 and Page 8 - Update the agency’s business hours.

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 the 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 54856 of the August 17, 2016, 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. In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at http://www.rrb.gov/pdf/PIA/PIA-BPO.pdf.

11. Sensitive questions - N.A.

12. Estimate of respondent burden - The current estimated annual burden for this collection is shown below.

Current Inventory

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
AA-5* Individuals Institutions	3,000 2,250 750	17	850.0 637.5 212.5
G-478	2,000	6	200.0
RB-5* Individuals Institutions	15,300 11,475 3,825	**60	15,300 11,475 3,825
Total	20,300		16,350

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

• Individuals

• Institutions/Nursing Homes

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

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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