Information Collection

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

IC 13881 under ICR 202012-1240-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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, Representative Payee Report (Short Form), 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-623 Representative Payee Report cm-623.pdf www.dol.gov/owcp/regs/compliance/cm-623.pdf Form and Instruction
CM-623S Representative Payee Report (Short Form) cm-623s.pdf www.dol.gov/owcp/regs/compliance/cm-623s.pdf Form and Instruction
CM-623S Representative Payee Report (Short Form) cm-623s.pdf www.dol.gov/owcp/regs/compliance/cm-623s.pdf Form and Instruction
CM-787 Physician's/Medical Officer's Statement 1240-0020 Physicians Medical Offcer's Statement (CM-787).pdf www.dol.gov/owcp/regs/compliance/cm-787.pdf Form and Instruction
CM-787 Physician's/Medical Officer's Statement 1240-0020 Physicians Medical Offcer's Statement (CM-787).pdf www.dol.gov/owcp/regs/compliance/cm-787.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Representative Payee Report, Representative Payee Report (Short Form), 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 20 CFR 725.506

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-623S	Representative Payee Report (Short Form)	cm-623s.pdf	http://www.dol.gov/owcp/regs/compliance/cm-623s.pdf	Yes	No	Fillable Printable
Form and Instruction	CM-787	Physician's/Medical Officer's Statement	1240-0020 Physicians Medical Offcer's Statement (CM-787).pdf	http://www.dol.gov/owcp/regs/compliance/cm-787.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-2	FR Citation: 67 FR 16870

Number of Respondents: 1,325	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,325	0	1,325
Annual IC Time Burden (Hours)	679	0	679
Annual IC Cost Burden (Dollars)	769	769	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.