OMB control number
Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement
OMB 1240-0020 · DOL/OWCP.
OMB 1240-0020
Representative Payee Report (CM-623) and Representative Payee Report Short Form (CM-623S) are used to ensure that benefits paid to a representative payee are being used for the beneficiary's well-being. Physician's/Medical Officer's Statement (CM-787) is used to determine the beneficiary's capability to manage monthly Black Lung benefits.
The latest form for Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement expires 2027-05-31 and is listed under ICR 202311-1240-007.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CM-787 Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement | Form |
| SS 1240-0024 CM-893 2023 final.docx | Supporting Statement A |
| 60-day FRN (1240-0020) published.pdf (document unavailable) | Supplementary Document |
| 20 CFR 725.506.pdf | Supplementary Document |
| 20 CFR 725.513.pdf | Supplementary Document |
| 20 CFR 725.512.pdf | Supplementary Document |
| 20 CFR 725.511.pdf | Supplementary Document |
| 20 CFR 725.510.pdf | Supplementary Document |
| 30 USC Subchapter IV (Sections 901-951).pdf | Supplementary Document |
 30-day FRN (1240-0020) published.pdf | Supplementary Document |
| System of Record Notice.pdf | Supplementary Document |
 Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement |
Form |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202311-1240-007 | Extension without change of a currently approved collection | 2024-03-29 | Approved with change | |
| 202012-1240-006 | Extension without change of a currently approved collection | 2021-03-15 | Approved without change | |
| 202010-1240-005 | No material or nonsubstantive change to a currently approved collection | 2020-10-23 | Approved without change | |
| 202003-1240-003 | No material or nonsubstantive change to a currently approved collection | 2020-04-12 | Approved without change | |
| 201710-1240-001 | Revision of a currently approved collection | 2018-02-01 | Approved without change | |
| 201405-1240-004 | Revision of a currently approved collection | 2014-10-14 | Approved without change | |
| 201107-1240-001 | Extension without change of a currently approved collection | 2011-09-29 | Approved without change | |
| 201003-1240-020 | Extension without change of a currently approved collection | 2010-03-12 | Approved without change |