OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement

ICR 202003-1240-003 · OMB 1240-0020 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-623 Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement Form and Instruction Unchanged Repair queued
Justification - Physician's Medical Officer's Statement - CM-787.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-03-09 Repair queued
CM-787 Physician's Medical Officer's Statement.pdf Supplementary Document Uploaded 2020-03-09 Repair queued
725.513.docx Supplementary Document Uploaded 2017-12-06 Available
725.511.docx Supplementary Document Uploaded 2017-12-06 Available
System of Record Notice.pdf Supplementary Document Uploaded 2017-12-06 Available
1240-0020 Supporting Statement 2018.docx Supporting Statement A Uploaded 2018-01-18 Repair queued
725.506 - 510.pdf Supplementary Document Uploaded 2014-08-01 Available
IC Document Collections
IC IDCollectionTypeStatusForm
13881 Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement Form and Instruction Unchanged
ICR Details
1240-0020 202003-1240-003
Historical Active 201710-1240-001
DOL/OWCP
Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 04/13/2020
Retrieve Notice of Action (NOA) 04/12/2020
  Inventory as of this Action Requested Previously Approved
04/30/2021 04/30/2021 04/30/2021
1,325 0 1,325
679 0 679
0 0 0
Requesting address change for CM-787. 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 922 Name of Law: Black Lung Benefits Act
  
None
Not associated with rulemaking
  82 FR 47772 10/13/2017
83 FR 5695 02/01/2018
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 1,325 1,325 0 0 0 0
Annual Time Burden (Hours) 679 679 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The total decrease in the total burden hours for all three forms is 963 hours, with the current total burden hours being 679. The prior total burden hours for all three forms were 1,642. Form CM-623 decreased by 900 hours, with a current burden of 450 hours. The CM-623S increased by 37 hours, with a current burden of 54 hours. The CM-787 decreased by 100 hours, with a current burden of 175 hours. The total decrease in the total burden hours for all three forms is 963 hours. The CM-623 and CM-623S are no longer used as the annual accounting of a beneficiary’s benefits, but rather are just used for the final accounting of a beneficiary’s benefits, due to death or due to a change in representative payee appointment. The number of burden hours for form CM-787 has decreased due to fewer determinations of incapability or incompetence medical opinions needed.
$13,857
No
    Yes
    Yes
No
No
No
Uncollected
Debbie Thurston 202 693-0913 [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.
04/12/2020