Information Collection

Representative Payee Report and Physician's/Medical Officer's Statement

IC 185863 under ICR 201405-1240-004 · OMB 1240-0020.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0020 can be found here:

Documents and Forms

Document Name Document Type
Form CM-623 Representative Payee Report and Physician's/Medical Officer's Statement Form and Instruction
CM-623 Representative Payee Report CM-623.pdf www.dol.gov/owcp/regs/compliance/cm-623.pdf Form and Instruction
CM-787 Physician's Medical Officer's Statement CM-787_working.pdf www.dol.gov/regs/regs/compliance/owcp/cm-787 Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Representative Payee Report and Physician's/Medical Officer's Statement	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 725.510 - .513

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CM-623	Representative Payee Report	CM-623.pdf	http://www.dol.gov/owcp/regs/compliance/cm-623.pdf	Yes	No	Fillable Printable
Form and Instruction	CM-787	Physician's Medical Officer's Statement	CM-787_working.pdf	http://www.dol.gov/regs/regs/compliance/owcp/cm-787	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: ESA-6	FR Citation: 67 FR 16870

Number of Respondents: 1,190	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,190	1,190
Annual IC Time Burden (Hours)	410	410
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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