Request to be Selected as Payee

ICR 200812-1215-005

OMB: 1215-0166

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2009-02-10
Supplementary Document
2009-02-02
Supplementary Document
2008-12-15
Supplementary Document
2008-12-15
IC Document Collections
IC ID
Document
Title
Status
13866 Modified
ICR Details
1215-0166 200812-1215-005
Historical Active 200601-1215-001
DOL/ESA
Request to be Selected as Payee
Extension without change of a currently approved collection   No
Regular
Approved without change 03/31/2009
Retrieve Notice of Action (NOA) 02/20/2009
  Inventory as of this Action Requested Previously Approved
03/31/2012 36 Months From Approved 04/30/2009
2,500 0 2,200
625 0 733
1,125 0 1,000

The CM-910 is used to obtain information about prospective representative payees to determine whether they are qualified to handle monetary benefits on behalf of a beneficiary under Part 901 of the Black Lung Benefits Act.

US Code: 30 USC Part 901 Name of Law: Black Lung Benefits Act
  
None

Not associated with rulemaking

  73 FR 61171 10/15/2008
74 FR 7926 02/20/2009
No

1
IC Title Form No. Form Name
Request to be Selected as Payee CM-910 Request To Be Selected As Payee

  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 2,500 2,200 0 0 300 0
Annual Time Burden (Hours) 625 733 0 0 -108 0
Annual Cost Burden (Dollars) 1,125 1,000 0 0 125 0
No
No
The total number of responses increased due to increased requests for the form. However, the total burden hour estimate has decreased due to adjusting the average response time from 20 to 15 minutes to complete the form. The increase in cost burden results from an increase in postage since the last submission.

$27,278
No
No
Uncollected
Uncollected
No
Uncollected
Michael McClaran 202-693-0978 [email protected]

  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.
02/20/2009


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