OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement

ICR 201107-1240-001 · OMB 1240-0020 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-623 Representative Payee Report Form and Instruction Modified Available
Form CM-623 Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement Form and Instruction Modified Repair queued
Supporting Statement for 1240-0020 (CM-623 CM-623S CM-787).doc Supporting Statement A Uploaded 2011-09-15 Repair queued
DOL Privacy Act systems ESA-30.pdf Supplementary Document Uploaded 2008-04-04 Available
DOL Privacy Act systems ESA-6.pdf Supplementary Document Uploaded 2008-04-04 Available
725.506 - 510.pdf Supplementary Document Uploaded 2008-04-04 Available
IC Document Collections
IC IDCollectionTypeStatusForm
185863 Representative Payee Report Form and Instruction Modified
13881 Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement Form and Instruction Modified
ICR Details
1240-0020 201107-1240-001
Historical Active 201003-1240-020
DOL/OWCP
Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement
Extension without change of a currently approved collection   No
Regular
Approved without change 10/31/2011
Retrieve Notice of Action (NOA) 09/29/2011
  Inventory as of this Action Requested Previously Approved
10/31/2014 36 Months From Approved 10/31/2011
2,100 0 2,100
1,642 0 1,642
0 0 0
Representative Payee Report (CM-623) and Representative Payee Report, Short Form (CM-623S) are used to ensure that benefits paid to a representative payee are being used for the beneficiary's well-being. Physician's/Medical Officer's Statement (CM-787) is used to determine the beneficiary's capability to manage monthly Black Lung benefits.
US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None
Not associated with rulemaking
  76 FR 24919 05/03/2011
76 FR 60533 09/29/2011
No
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 2,100 2,100 0 0 0 0
Annual Time Burden (Hours) 1,642 1,642 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$28,883
No
No
No
No
No
Uncollected
Michael McClaran 202-693-0978 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/29/2011