Information Collection

Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement

IC 13881 under ICR 202012-1240-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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, Representative Payee Report (Short Form), 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-623 Representative Payee Report cm-623.pdf www.dol.gov/owcp/regs/compliance/cm-623.pdf	Form and Instruction
CM-623S Representative Payee Report (Short Form) cm-623s.pdf www.dol.gov/owcp/regs/compliance/cm-623s.pdf	Form and Instruction
CM-623S Representative Payee Report (Short Form) cm-623s.pdf www.dol.gov/owcp/regs/compliance/cm-623s.pdf	Form and Instruction
CM-787 Physician's/Medical Officer's Statement 1240-0020 Physicians Medical Offcer's Statement (CM-787).pdf www.dol.gov/owcp/regs/compliance/cm-787.pdf	Form and Instruction
CM-787 Physician's/Medical Officer's Statement 1240-0020 Physicians Medical Offcer's Statement (CM-787).pdf www.dol.gov/owcp/regs/compliance/cm-787.pdf	Form and Instruction

IC Title:

Representative Payee Report, Representative Payee Report (Short Form), 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 20 CFR 725.506

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-623S	Representative Payee Report (Short Form)	cm-623s.pdf	http://www.dol.gov/owcp/regs/compliance/cm-623s.pdf	Yes	No	Fillable Printable
Form and Instruction	CM-787	Physician's/Medical Officer's Statement	1240-0020 Physicians Medical Offcer's Statement (CM-787).pdf	http://www.dol.gov/owcp/regs/compliance/cm-787.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/OWCP-2

FR Citation: 67 FR 16870

Number of Respondents: 1,325

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,325	0	1,325
Annual IC Time Burden (Hours)	679	0	679
Annual IC Cost Burden (Dollars)	769	769	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.