Request to be Selected as Payee

ICR 202404-1240-001

OMB: 1240-0010

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2024-07-25
Supplementary Document
2021-08-23
Supplementary Document
2018-03-19
Supplementary Document
2009-02-02
IC Document Collections
IC ID
Document
Title
Status
13866 Modified
ICR Details
1240-0010 202404-1240-001
Received in OIRA 202107-1240-001
DOL/OWCP
Request to be Selected as Payee
Extension without change of a currently approved collection   No
Regular 07/31/2024
  Requested Previously Approved
36 Months From Approved 10/31/2024
350 200
88 50
230 80

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.

US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None

Not associated with rulemaking

  89 FR 24867 04/09/2024
89 FR 61499 07/31/2024
No

1
IC Title Form No. Form Name
Request to be Selected as Payee CM-910 Request To Be Selected As Payee

  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 350 200 0 0 150 0
Annual Time Burden (Hours) 88 50 0 0 38 0
Annual Cost Burden (Dollars) 230 80 0 0 150 0
No
No
EXPLANATION OF CHANGE TOTALS Respondents: The number of respondents increased from 200 to 350. The number of respondents increase due to a increase of requests to be selected as Payee. The following also increased due to an increased in number of forms received/responses. Responses: Responses have increased from 200 to 350. Burden Hours: Burden hours have increased from 50 to 87. The following Increased due to program changes in mailing cost. Costs: Annual burden costs have increased from $80.00 to $230.00.

$230
No
    Yes
    Yes
No
No
No
No
Anjanette Suggs 202 354-9660 suggs.anjanette@dol.gov

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/31/2024


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