Request to be Selected as Payee

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-910 Request to be Selected as Payee	Form	Modified	Available
NOTICE TO REVIEWER.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2016-02-10	Available
2014 SUPPORTING STATEMENT 1240-0010 (CM-910).docx	Supporting Statement A	Uploaded 2015-02-10	Available
20 CFR 725.505-513 for 1215-0166.pdf	Supplementary Document	Uploaded 2009-02-02	Available
DOL Privacy Act systems ESA-30.pdf	Supplementary Document	Uploaded 2008-12-15	Available
DOL Privacy Act systems ESA-6.pdf	Supplementary Document	Uploaded 2008-12-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13866	Request to be Selected as Payee	Form	Modified

ICR Details

OMB Control No: 1240-0010	ICR Reference No: 201602-1240-002
Status: Historical Active	Previous ICR Reference No: 201412-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request to be Selected as Payee
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/17/2016
	Date Received in OIRA: 03/14/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2018	06/30/2018	06/30/2018
Responses	2,300	0	2,300
Time Burden (Hours)	575	0	575
Cost Burden (Dollars)	1,196	0	1,196

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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:
	79 FR 73340	12/10/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 17507	04/01/2015
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

table that charts list 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	2,300	0	0	0	0
Annual Time Burden (Hours)	575	575	0	0	0	0
Annual Cost Burden (Dollars)	1,196	1,196	0	0	0	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:

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Annual Cost to Federal Government: $29,371

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: 03/14/2016

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