Request to be Selected as Payee

OMB 1240-0010

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.

The latest form for Request to be Selected as Payee expires 2021-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CM-910 Request to be Selected as Payee Form
Supporting Statement 1240-0010 Final.docx Supporting Statement A
DOL_OWCP-9 _ U.S. Department of Labor.pdf Supplementary Document
System of Record Notice-DOL OWCP-2.pdf Supplementary Document
20 CFR 725.505-513 for 1215-0166.pdf Supplementary Document
Request to be Selected as Payee Form

All Historical Document Collections

202404-1240-001 Approved without change	Extension without change of a currently approved collection	2024-07-31
202107-1240-001 Approved without change	Extension without change of a currently approved collection	2021-08-30
201803-1240-004 Approved without change	Revision of a currently approved collection	2018-06-29
201602-1240-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-03-14
201412-1240-001 Approved without change	Revision of a currently approved collection	2015-04-01
201201-1240-001 Approved without change	Extension without change of a currently approved collection	2012-03-29
201003-1240-010 Approved without change	Extension without change of a currently approved collection	2010-03-12