Representative Payee Report (CM-623)
and Representative Payee Report Short Form (CM-623S) are used to
ensure that benefits paid to a representative payee are being used
for the beneficiary's well-being. Physician's/Medical Officer's
Statement (CM-787) is used to determine the beneficiary's
capability to manage monthly Black Lung benefits.
US Code:
30
USC 922 Name of Law: Black Lung Benefits Act
The total decrease in the total
burden hours for all three forms is 963 hours, with the current
total burden hours being 679. The prior total burden hours for all
three forms were 1,642. Form CM-623 decreased by 900 hours, with a
current burden of 450 hours. The CM-623S increased by 37 hours,
with a current burden of 54 hours. The CM-787 decreased by 100
hours, with a current burden of 175 hours. The total decrease in
the total burden hours for all three forms is 963 hours. The CM-623
and CM-623S are no longer used as the annual accounting of a
beneficiary’s benefits, but rather are just used for the final
accounting of a beneficiary’s benefits, due to death or due to a
change in representative payee appointment. The number of burden
hours for form CM-787 has decreased due to fewer determinations of
incapability or incompetence medical opinions needed.
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.