Information Collection

Representative Payee Report and Physician's/Medical Officer's Statement

IC 185863 under ICR 201405-1240-004 · OMB 1240-0020.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0020 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-623 Representative Payee Report and Physician's/Medical Officer's Statement	Form and Instruction
CM-623 Representative Payee Report CM-623.pdf www.dol.gov/owcp/regs/compliance/cm-623.pdf	Form and Instruction
CM-787 Physician's Medical Officer's Statement CM-787_working.pdf www.dol.gov/regs/regs/compliance/owcp/cm-787	Form and Instruction

IC Title:

Representative Payee Report and Physician's/Medical Officer's Statement

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.pdf	http://www.dol.gov/owcp/regs/compliance/cm-623.pdf	Yes	No	Fillable Printable
Form and Instruction	CM-787	Physician's Medical Officer's Statement	CM-787_working.pdf	http://www.dol.gov/regs/regs/compliance/owcp/cm-787	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: 1,190

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,190	1,190
Annual IC Time Burden (Hours)	410	410
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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