Information Collection

Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement

IC 13881 under ICR 200804-1215-001 · OMB 1215-0173.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-623 Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement	Form and Instruction
CM-623 Representative Payee Report CM-623 Draft 7-24-2008.doc www.dol.gov/esa/owcp/regs/compliance/cm-623.pdf	Form and Instruction
CM-623S Representative Payee Report (Short Form) CM-623S Draft 7-24-08.doc www.dol.gov/esa/owcp/regs/compliance/cm-623s.pdf	Form and Instruction
cm-623 7-99 version.pdf CM-623	IC Document
cm-623s 12-99 version.pdf CM-623S	IC Document

IC Title:

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:

table that charts list of 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 Draft 7-24-2008.doc	http://www.dol.gov/esa/owcp/regs/compliance/cm-623.pdf	Yes	No	Fillable Printable
Form and Instruction	CM-623S	Representative Payee Report (Short Form)	CM-623S Draft 7-24-08.doc	http://www.dol.gov/esa/owcp/regs/compliance/cm-623s.pdf	Yes	No	Fillable Printable

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	910	-4,429	5,339
Annual IC Time Burden (Hours)	1,232	-4,198	5,430
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CM-623	cm-623 7-99 version.pdf	07/31/2008
CM-623S	cm-623s 12-99 version.pdf	07/31/2008

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