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Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement
Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement
OMB: 1215-0173
IC ID: 13881
OMB.report
DOL/ESA
OMB 1215-0173
ICR 200508-1215-002
IC 13881
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0173 can be found here:
2008-08-07 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CM-787
No
No
Form
CM-623S
No
No
Form
CM-623
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
5,339
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
5,339
0
0
2,241
0
3,098
Annual IC Time Burden (Hours)
5,430
0
0
1,861
0
3,569
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.