REQUEST TO BE SELECTED AS PAYEE

ICR 199310-1215-001

OMB: 1215-0166

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
122350 Migrated
ICR Details
1215-0166 199310-1215-001
Historical Active 199107-1215-001
DOL/ESA
REQUEST TO BE SELECTED AS PAYEE
Extension without change of a currently approved collection   No
Regular
Approved without change 01/07/1994
Retrieve Notice of Action (NOA) 10/21/1993
  Inventory as of this Action Requested Previously Approved
02/28/1997 02/28/1997 01/31/1994
600 0 600
200 0 200
0 0 0

IF A BENEFICIARY IS INCAPABLE OF HANDLING HIS/HER OWN AFFAIRS, THE LEGAL GUARDIAN OR OTHER RESPONSIBLE PARTY MAY APPLY TO RECEIVE THE BENEFITS ON BEHALF OF THE BENEFICIARY AS A REPRESENTATIVE PAYEE. THE CM-910 IS THE FORM THE POTENTIAL REPRESENTATIVE PAYEE MUST SUBMIT TO DCMWC'S STAFF FOR REVIEW TO DETERMINE IF THE REQUEST CAN BE APPROVED.

None
None


No

1
IC Title Form No. Form Name
REQUEST TO BE SELECTED AS PAYEE CM-910

  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 600 600 0 0 0 0
Annual Time Burden (Hours) 200 200 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
10/21/1993


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