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 202010-1240-005 · OMB 1240-0020 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form CM-787 Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement Form and Instruction Modified Available
Justification - Physician's Medical Officers Statement (CM-787).docx Justification for No Material/Nonsubstantive Change Uploaded 2020-10-22 Available
725.513.docx Supplementary Document Uploaded 2017-12-06 Available
725.511.docx Supplementary Document Uploaded 2017-12-06 Repair queued
System of Record Notice.pdf Supplementary Document Uploaded 2017-12-06 Repair queued
1240-0020 Supporting Statement 2018.docx Supporting Statement A Uploaded 2018-01-18 Available
725.506 - 510.pdf Supplementary Document Uploaded 2014-08-01 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
13881 Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement Form and Instruction Modified
ICR Details
1240-0020 202010-1240-005
Active 202003-1240-003
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 11/03/2020
Retrieve Notice of Action (NOA) 10/23/2020
  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
$13,857
No
    Yes
    Yes
No
No
No
No
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.
10/23/2020