View Information Collection (IC)

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

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_working.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_working.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	CM-787_working.pdf	http://www.dol.gov/owcp/regs/compliance/cm-787.pdf	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

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: 910	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	910	0	0	0	0	910
Annual IC Time Burden (Hours)	1,232	0	0	0	0	1,232
Annual IC Cost Burden (Dollars)	0	0	0	0	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.