Cm-623s

U.S. Department of Labor

Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

OMB No.:1215-0173
Expires: 10-31-08

REPRESENTATIVE PAYEE REPORT
INSTRUCTIONS
All representative payees are required to report annually. This is your Representative Payee Report.
You must complete and return the report. The report will be reviewed by the U.S. Department of
Labor and is subject to verification. If you need help completing the report, please contact the office
listed above by mail or telephone. THIS REPORT MUST BE COMPLETED AND RETURNED WITHIN 30
DAYS OR BENEFITS MAY BE AFFECTED.
YOUR JOB AS A REPRESENTATIVE PAYEE
Your job as a representative payee is to use the Black Lung benefits you receive for the personal care
and well-being of the beneficiary. You must keep yourself informed of the beneficiary's needs so you
can decide how the benefits should be used. You must notify the U.S. Department of Labor when the
beneficiary changes residence or if you no longer exercise responsibility for the care and welfare of
the beneficiary. You must report the beneficiary's death, marriage, adoption, employment, or release
from an institution. You must also report the beneficiary's receipt of any State Workers' Compensation
Benefits. If the person for whom you receive benefits is a student or is disabled, you must report any
changes in school attendance or disability status.
NOTICE
Whoever, having received a payment for the use and benefit of another person, knowingly and willfully
uses such payment for other than the use and benefit of the person for whom it is received, is subject
to a fine, imprisonment or both.
PAPERWORK/PRIVACY ACT NOTICE
The following statement is made in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a).
This report is authorized by law (30 USC 922 section 20 CFR 725.513). The information you furnish on
this form may be routinely disclosed without your consent to another person or Government agency for
purposes such as (1) to comply with Federal laws requiring the release of information from our
records; or (2) to conduct research and audit activities needed to assure the continuing integrity and
improvement of the U.S. Department of Labor representative payee program. Other routine disclosures
of this information are listed in the Federal Register, which will be made available upon request.
PUBLIC BURDEN STATEMENT
We estimate that it will take an average of 10 minutes per response to complete this collection of
information, including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. If you have
any comments regarding these estimates or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to the, U.S. Department of Labor, Division of
Coal Mine Workers' Compensation, Room N-3464, 200 Constitution Avenue, N.W., Washington, D.C.
20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid

OMB control number.

Form CM-623S
Rev. Dec. 1999

REPRESENTATIVE PAYEE REPORT
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Name and address of beneficiary:

Name and address of representative payee:

name:
line 1:
line 2:

DEPARTMENT OF LABOR
USE ONLY

to

This report is for the period from :

city:
state:

city:
state:

zip:

zip:

Claim Number.

1. a) Have you lived in the same household as the beneficiary for the whole reporting period?
b) If no, please explain in the comments section below.
Yes
2. How are you related to the beneficiary? (wife, son, daughter, etc

No

)

3. Were all of the beneficiary's benefits, which you received during this reporting period, used or
saved for the beneficiary?
Yes

No

4. a) Were benefits spent for the beneficiary on items other than for food, shelter, medical and
personal needs?
Yes

No

b) If yes, briefly explain:

COMMENTS (This space is for any comments you may have concerning your position and responsibilities as
representative payee):

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE INSTRUCTIONS ON THIS FORM AND THAT THE INFORMATION WHICH I HAVE
PROVIDED ON THIS FORM IS TRUE.
SIGNATURE OF PAYEE (if signed by mark (X), two witnesses must sign below)

TELEPHONE NUMBER (include area code)

DATE
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BUSINESS
WITNESS SIGNATURES ARE REQUIRED ONLY IF THE PAYEE's SIGNATURE ABOVE HAS BEEN SIGNED BY MARK (X)
SIGNATURE OF WITNESS

DATE

SIGNATURE OF WITNESS

DATE