1240-0010 CM-910 Supporting Statement 8.30.21 FINAL

[Request to be Selected as Payee]

OMB Control Number 1240-0010

OMB Expiration Date: 10/31/2021

SUPPORTING STATEMENT FOR

Request to be Selected as Payee

OMB CONTROL NO. 1240-0010

This ICR seeks to extend this information collection.

1. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

The Black Lung Benefits Act (30 U.S.C. 901) and its implementing regulations necessitate this information collection. The regulations at 20 CFR 725.505-513 authorize the collection of this information. If a beneficiary is incapable of handling his/her affairs, the person or institution responsible for their care is required to apply to receive the benefit payments on the beneficiary's behalf. The CM 910 is the form completed by representative payee applicants. The payee applicant completes the form and submits it for evaluation to the district office that has jurisdiction over the beneficiary's claim file.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

The representative payee applicant completes the form and returns it to the district office. Upon receipt of the collected information, the claims staff reviews the information to determine the relationship of the applicant to the beneficiary and to assess the applicant's ability to undertake the responsibilities of a representative payee.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also, describe any consideration of using information technology to reduce burden.

The form CM‑910 is available for downloading at http://www.dol.gov/owcp/dcmwc/regs/compliance/blforms.htm. The CM-910 can also be accessed through the Department of Labor’s on-line forms library at http://webapps.dol.gov/libraryforms/

The form can be filled out on-screen, printed, and mailed or may be printed, completed by hand, and mailed. The completed form may also be submitted online through the COAL Mine Portal at https://eclaimant.dol.gov/portal/?program_name=BL.  It has been made available for electronic submission.  The form requires the signature of the applicant, which could be affixed electronically, but also contains a space for the signature of a witness if the applicant is unable to sign his or her name.  Two independently-obtained digital signatures by different people would be required to submit such a form on-line and, in order to keep claim information confidential, the Department of Labor’s website does not permit forwarding or submission of on-line forms to any place other than the Department’s designated electronic mailbox.  This would prevent the applicant from forwarding the form to the witness after both had received their digital signature verification keys.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.

There is no similar information available.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The collection of this information does not impose a significant impact on small entities.

6. Describe the consequence to federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

This information is collected only once when an institution or individual completes the application and submits it for evaluation. If this information were not collected, the Program would be unable to evaluate the applicant's ability to be a representative payee. Thus, the beneficiary's best interests would not be served, if the Program were not able to screen representative payee applicants.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

There are no special circumstances for this information collection.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

A Federal Register Notice inviting public comment was published on June 24, 2021 (86 FR 33375). No public comments were received.

9. Explain any decision to provide any payments or gifts to respondents, other than remuneration of contractors or grantees.

No payments or gifts are made to respondents to furnish the information.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

Since the completed form is maintained in the beneficiary’s case file, the information collected is covered by the Privacy Act System of Records, DOL/OWCP-2 and DOL/OWCP-9, published at 81 Federal Register 25765, 25858, and 25866 (April 29, 2016), or as updated and republished.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

This collection contains no questions of a sensitive nature.

12. Provide estimates of the hour burden of the collection of information. The statement should:

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

Estimated Annualized Respondent Cost and Hour Burden

Activity	No. of Respondents	No. of Responses per Respondent	Total Responses	Average Burden (Hours)	Total Burden (Hours)	Hourly Wage Rate	Total Burden Cost
CM-910	200	1	200	15 min.	50	$24.60	$1,230.00

It is not possible to determine the specific occupation or wages for each person who will provide the information covered by this clearance, and wages can vary considerably from person to person depending on duties and length of service, and because the respondent may not be employed at all. Therefore, we are using the national median weekly wage to estimate the annualized burden cost. This estimate is derived from use of the Median Weekly Earnings of Full-time and Salary Workers for 2020 ($984.00), as computed by the Bureau of Labor Statistics (https://www.bls.gov/news.release/archives/wkyeng_01212021.pdf).Accordingly, the calculations for the estimated annualized burden cost are as follows:

$984.00/ 40=$24.60x50 hrs. =$1,230.00.

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

• The cost estimate should be split into two components: (a) a total capital

and start up cost component (annualized over its expected useful life); and (b) a

total operation and maintenance and purchase of service component.

The estimates should take into account costs associated with generating,

maintaining, and disclosing or providing the information. Include descriptions of

methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

• If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

• Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.

There are no technological or system costs associated with the collection of the CM-910 information. A mailing and envelope cost to the respondent of 53¢ ($.50 stamp plus $.03 envelope) is applicable as an operation cost, for a total of $106.00 (53¢ X 200 respondents). We received 50 responses through the COAL MINE portal; this forms reduced the operation cost by 25%. The original estimated cost of $106.00 minus the 25% from the forms received electronically changes the operational cost to $80.00 (rounded up).

14. Provide estimates of the annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 into a single table.

The estimated total cost to the Federal Government for the 200 forms is $80, the estimated mailing cost.

15. Explain the reasons for any program changes or adjustments.

There has been a decrease in the number of respondents (250 – 200) due to fewer applicants applying to become representative payees for beneficiaries. The cost burden to respondents has also decreased as result of a portion of filers submitting the form electronically.

16. For collections of information whose results will be published, outline plans for tabulations, and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

There are no plans to publish this collection of information.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

This ICR does not seek a waiver from the requirement to display the expiration date.

18. Explain each exception to the certification statement.

There are no exceptions to the certification statement.

B. COLLECTIONS OF INFORMATON EMPLOYING STATISTICAL METHODS.

Statistical methods are not used in these collections of information.

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