Request to be Selected as Payee

Forms and Documents

Document Name	Status
Form CM-910 Request to be Selected as Payee Form	Modified
SUPPORTING STATEMENT 1240-0010 (CM-910).docx Supporting Statement A	2012-03-23
20 CFR 725.505-513 for 1215-0166.pdf Supplementary Document	2009-02-02
DOL Privacy Act systems ESA-30.pdf Supplementary Document	2008-12-15
DOL Privacy Act systems ESA-6.pdf Supplementary Document	2008-12-15

IC Document Collections

IC ID	Document Title	Status
13866	Request to be Selected as Payee Form	Modified

ICR Details

OMB Control No: 1240-0010	ICR Reference No: 201201-1240-001
Status: Historical Active	Previous ICR Reference No: 201003-1240-010
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request to be Selected as Payee
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/08/2012
	Date Received in OIRA: 03/29/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2015	36 Months From Approved	05/31/2012
Responses	2,300	0	2,500
Time Burden (Hours)	575	0	625
Cost Burden (Dollars)	1,104	0	1,125

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Abstract: 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.

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Authorizing Statute(s): US Code: 30 USC 901 et seq. Name of Law: Black Lung Benefits Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 1513	01/10/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 19035	03/29/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

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

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ICR Summary of Burden

	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	2,300	2,500	0	0	-200	0
Annual Time Burden (Hours)	575	625	0	0	-50	0
Annual Cost Burden (Dollars)	1,104	1,125	0	0	-21	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The total number of responses decreased from 2,500 to 2,300 for an adjustment of -200. The total burden hour estimate has decreased since the last clearance from 833 hours to 767 burden hours for an adjustment of -66 hours. The decrease in total responses is due to the aging population of our beneficiaries. Most of our beneficiaries are in the advanced age of life, many with other ailments in addition to having black lung disease. With having so many beneficiaries in the advanced age of life, we lose many due to death.

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Annual Cost to Federal Government: $27,278

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 03/29/2012

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