Cm-623

U.S. Department of Labor

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

REPRESENTATIVE PAYEE REPORT
INSTRUCTIONS

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

All representative payees are required to account annually. This is your Representative Payee Report.
You must complete and return the report whether you are the beneficiary's relative, friend, or
court-appointed guardian, or you are an official of a bank or a public or private agency or institution.
You should keep a record of the amount of benefits you received and how you used them because the
report will be reviewed by the U.S. Department of Labor and is subject to verification. You will be
notified if verification is required. DO NOT submit receipts, canceled checks, etc., with this report. 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 a hospital or institution. You must also report the beneficiary's receipt of any State Workers'
Compensation Benefits and changes in school attendance or disability status, if the person for whom
you receive benefits is a student or disabled.
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). Your cooperation is needed to
insure that Black Lung benefits are being received in the correct amount and that the beneficiary's
needs are being met. Failure to provide all or part of this information could prevent an accurate and
timely decision as to your continued suitability as representative payee. 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 90 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-623
Rev. Jul. 1999

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REPRESENTATIVE PAYEE REPORT
Identifying Information
Department of Labor Only

to

This report is for the period from:

Name and address of beneficiary:

Name and address of representative payee:

City

City
State

line 1:

Zip
Claim Number:
1a. Show below all places where the beneficiary lived during the report period shown above. (Check appropriate box and supply
information.)
With an unrelated person (answer 1b.)
With you
With a relative (answer 1b.)
State

Zip

in a public institution: hospital, home for aged, nursing home, etc. (answer 1b.)
Date of residence:

1b. Give the name and address of each person with whom the beneficiary lived.
from

to

City
State

Zip

City
State

Zip

2. How did you find out what the beneficiary's needs were, if the beneficiary did not live with you?

3. Do you maintain contact with the beneficiary by:
Same household

Yes

No

Visit

Yes

No

Telephone

Yes

No

4. Funds on hand from Black Lung benefits at beginning of this report period. if you have filed a
previous U.S. Department of Labor Black Lung Representative Payee accounting report, this
amount should be the same as the figure shown on your last report (item #9) as remaining
balance

$

5. Total Black Lung benefits received during this reporting period-

$

6. Total Black lung funds available during this reporting period(item #4 plus item #5.)

$

7. How available Black Lung funds were used during this reporting period:
a. Amount used for beneficiary's food and shelter
(Show in ''REMARKS'' section of this report the name and address of the person or entity
receiving your food and shelter payments.)
b. Amount used for beneficiary's clothingc. Amount used for beneficiary's medical and dental care
d. Amount used for personal needs of beneficiarye. Amount used for support of beneficiary's dependents
f. Amount used for other items: (show purpose for which funds were used in ''REMARKS''
section of this report).

$

$
$
$
$
$

8. Total amount used during this reporting period: (Add 7a. through 7f.)

$

9. Balance remaining at end of this period: (Item 6 minus 8.)

$

Letter

Yes

No

10. How is balance in item #9 held, saved, or invested?
TITLE/OWNERSHIP*

AMOUNT
$

Cash
Checking account

$

insured savings account

$

U. S. Savings Bonds

$

other (Specify)

$

• Specify who's name(s) appear on each account, i.e., "Your name for beneficiary", "Beneficiary's name by your name'', "Your
name on-behalf-of (OBO) beneficiary", etc.
Benefits shall be held in an account which shows that the money belongs to the beneficiary. If you are not sure whether
the account you have established shows this ownership, you should consult your bank and, if necessary, change the
account title appropriately.

NOTE:

11. If all benefits listed in item #6 of this report were held, saved, or invested, please explain how beneficiary's needs were met.

12. During this period, did the beneficiary have any income other than U.S. Department of Labor Black Lung benefits?
Yes

No

If yes, list sources of other income:
FREQUENCY OF PAYMENT

AMOUNT

SOURCE

13. Have you ever been convicted of a felony?

Yes

No

if yes, explain below, in remarks section.

REMARKS:

The penalty upon conviction for the misuse of benefits by a representative payee is a fine and/or imprisonment for up to five (5) years for
the first offense, pursuant to Public Law 98-450. A second offense is punishable by up to five (5) years of imprisonment and/or a fine not
exceeding $25,000. The court may also order restitution.
I CERTIFY THAT THE INFORMATION I HAVE GIVEN ON THIS FORM IS TRUE.
SIGNATURE OF PAYEE (If signed by mark (X), two witnesses must sign below)

RELATIONSHIP TO BENEFICIARY OR TITLE

TELEPHONE NUMBER (include area code)

DATE
HOME

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