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

Documents and Forms

Document Name Document Type
Form CM-787 Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement Form
CM-787 Physician's/Medical Officer's Statement CM-787 form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-787 Physician's/Medical Officer's Statement CM-787 form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-623 Representative Payee Report CM-623 form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-623 Representative Payee Report CM-623 form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-623S Representative Payee Report (short version) CM-623S Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-623S Representative Payee Report (short version) CM-623S Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-787	Physician's/Medical Officer's Statement	CM-787 form.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-623	Representative Payee Report	CM-623 form.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-623S	Representative Payee Report (short version)	CM-623S Form.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	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: 282	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	282	-1,043	1,325
Annual IC Time Burden (Hours)	154	-525	679
Annual IC Cost Burden (Dollars)	192	-577	769

Documents for IC

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.