Request to be Selected as Payee

Forms and Documents

Document Name	Status
Form CM-910 Request to be Selected as Payee Form	Modified
Justification 910.docx Justification for No Material/Nonsubstantive Change	2025-08-05
Supporting Statement 1240-0010 Final.docx Supporting Statement A	2024-07-25
DOL_OWCP-9 _ U.S. Department of Labor.pdf Supplementary Document	2021-08-23
System of Record Notice-DOL OWCP-2.pdf Supplementary Document	2018-03-19
20 CFR 725.505-513 for 1215-0166.pdf Supplementary Document	2009-02-02

IC Document Collections

IC ID	Document Title	Status
13866	Request to be Selected as Payee Form	Modified

ICR Details

OMB Control No: 1240-0010	ICR Reference No: 202508-1240-001
Status: Received in OIRA	Previous ICR Reference No: 202411-1240-001
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	Date Submitted to OIRA: 08/12/2025

	Requested	Previously Approved
Expiration Date	09/30/2027	09/30/2027
Responses	350	350
Time Burden (Hours)	88	88
Cost Burden (Dollars)	230	230

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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 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:
	89 FR 24867	04/09/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 61499	07/31/2024
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Request to be Selected as Payee	CM-910, CM-910, CM-910	Request To Be Selected As Payee ,   Request To Be Selected As Payee ,   Request to be selected as Payee

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ICR Summary of Burden

	Total Request	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	350	350	0	0	0	0
Annual Time Burden (Hours)	88	88	0	0	0	0
Annual Cost Burden (Dollars)	230	230	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: $230

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

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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: 08/12/2025

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