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 can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
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All Historical Document Collections

202311-1240-007 Approved with change	Extension without change of a currently approved collection	2024-03-29
202012-1240-006 Approved without change	Extension without change of a currently approved collection	2021-03-15
202010-1240-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-10-23
202003-1240-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-04-12
201710-1240-001 Approved without change	Revision of a currently approved collection	2018-02-01
201405-1240-004 Approved without change	Revision of a currently approved collection	2014-10-14
201107-1240-001 Approved without change	Extension without change of a currently approved collection	2011-09-29
201003-1240-020 Approved without change	Extension without change of a currently approved collection	2010-03-12