Information Collection

Representative Payee Report, Representative Payee Report (short Form), And Physician's/medical Officer's Statement

IC 122367 under ICR 199309-1215-001 · OMB 1215-0173.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0173 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

No indexed documents/forms are available for this IC yet. A refresh has been queued.

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: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	CM-623	No	No
Form	CM-623S	No	No
Form	CM-787	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,448

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,448	-27,552	30,000
Annual IC Time Burden (Hours)	2,207	-273	2,480
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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