Representative Payee Report

U.S. Department of Labor                                                         Reset            Print
Office of Workers' Compensation
Division of Coal Mine Workers’ Compensation

                                                                                                                                          OMB No.: 1240-0020
REPRESENTATIVE PAYEE REPORT                                                                                                               Expires: 05/31/2027

                                                          INSTRUCTIONS
This is your Representative Payee Report. You are required to file it when the beneficiary dies, when you are no longer serving
as the beneficiary’s representative payee, or at OWCP’s request. You must complete and return the report whether you are
the beneficiary’s relative, friend, or court appointed guardian, or you are an official of a bank or a public or private agency or
institution. You should keep a record of the amount of benefits you received and how you used them, because the report will
be reviewed by the U. S. Department of Labor and is subject to verification. You will be notified if verification is required. DO
NOT submit receipts, canceled checks, etc., with this report. If you need help completing the report, please call your nearest
Black Lung Office at the toll-free 800-number shown in the list below. This report must be completed and returned within 30
days.
                                          YOUR JOB AS A REPRESENTATIVE PAYEE
Your job as a representative payee is to use the Black Lung benefits you receive for the personal care and well-being of the
beneficiary. You must keep yourself informed of the beneficiary’s needs so you can decide how the benefits should be used.
You must notify the U.S. Department of Labor when the beneficiary changes residence or if you no longer exercise
responsibility for the care and welfare of the beneficiary. You must report the beneficiary’s death, marriage, adoption,
employment, or release from a hospital or institution. You must also report the beneficiary’s receipt of any State Workers’
Compensation Benefits and changes in school attendance or disability status, if the person for whom you receive benefits is a
student or disabled.
                                                              NOTICE
If you misuse benefits received as a representative payee, you may be convicted of a felony and fined under Title 18, U.S.C., or
imprisoned for not more than 5 years, or both. The court may also order restitution. 42 U.S.C. 408, incorporated by 30 U.S.C.
923(b), 940.
                                   BLACK LUNG DISTRICT OFFICES TOLL-FREE NUMBER
                                                           1-800-347-2502
                                    Greensburg, PA                         Johnstown, PA
                                    Charleston, WV                         Pikeville, KY
                                    Denver, CO                             Columbus, OH


                                                                    PRIVACY ACT NOTICE
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) the Black Lung Benefits Act (BLBA) (30 U.S.C. 901
et seq.), as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of Labor, which receives and
maintains personal information, relative to this application, on claimants and their immediate families; (2) information obtained by OWCP will be used to
determine eligibility for benefits payable under the BLBA; (3) information may be given to other government agencies, coal mine operators potentially liable for
payment of the claim or to the insurance carrier or other entity which secured the operator's compensation liability, contractors providing automated data
processing services to the Department of Labor; and representatives of the parties to the claim; (4) information may be given to physicians or other medical
service providers for use in providing treatment, making evaluations and for other purposes relating to the medical management of the claim; (5) information
may be given to the Department of Labor's Office of Administrative Law Judges, or other person, board or organization, which is authorized or required to
render decisions with respect to the claim or other matters arising in connection with the claim; (6) information may be given to Federal, state or local agencies
for law enforcement purposes, to obtain information relevant to a decision under the BLBA, to determine whether benefits are being or have been paid properly,
and where appropriate, to pursue administrative offset and/or debt collection actions required or permitted by law; (7) disclosure of the claimant's or deceased
miner's Social Security Number (SSN) or tax identifying number (TIN) on this form is voluntary, and the SSN and/or TIN and other information maintained by
the OWCP may be used for identification and for other purposes authorized by law; (8) failure to disclose all requested information, may delay the processing of
this claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits; and (9) this information is included in a System of
Records, DOL/OWCP-2 published at 81 Federal Register 25765, 25858 (April 29, 2016) or as updated and republished.
                                                                PUBLIC BURDEN STATEMENT
We estimate that it will take an average of 90 minutes per response to complete this collection of information, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any
comments regarding these estimates or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S.
Department of Labor, Division of Coal Mine Workers’ Compensation, 200 Constitution Avenue, N.W., Suite C3520-DCMWC Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
                                                                            NOTICE
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in the
form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of
documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the
limitations of your disability. Please contact our office or the claims staff to ask about this assistance.


                                                                                                                                             CM-623 (01/2024)
                                                       REPRESENTATIVE PAYEE REPORT

                                                                                                                IDENTIFYING INFORMATION
  This report is for the period from:                     To:
                                                                                                             DEPARTMENT OF LABOR USE ONLY
Name and address of representative payee:                                 Name and address of beneficiary:




                                                                           DOL's Case ID Number:

1a. Show below all places where the beneficiary lived during the report period shown above. (Check appropriate box and supply information.)
       With you           With a relative (answer 1b.)       With an unrelated person (answer 1b.)
       In a public institution: hospital, home for aged, nursing home, etc. (answer 1b.)

1b. Give the name and address of each person with whom the beneficiary lived.
Name and Address                                                                                             Date of residence:
                                                                                                                From:

                                                                                                                To:

Name and Address                                                                                             Date of residence:
                                                                                                                From:

                                                                                                                To:


2. How did you find out what the beneficiary's needs were, if the beneficiary did not live with you?




3. Do you maintain contact with the beneficiary by:
  Same household         Yes            No     Visit   Yes           No       Telephone       Yes      No             Letter   Yes       No

4. Funds on hand from Black Lung benefits at beginning of this report period. If you have filed a previous U.S.
Department of Labor Black Lung Representative Payee accounting report, this amount should be the same as
the figure shown on your last report (item #9) as remaining balance.

5. Total Black Lung benefits received during the reporting period:
6. Total Black Lung funds available during this reporting period: (Item #4 plus #5)
7. How available Black Lung benefits were used during the reporting period:

  a. Amount used for beneficiary’s food and shelter: (Show in “REMARKS” section of this report the
  name and address of the any person or entity receiving food and shelter payments.)

  b. Amount used for beneficiary’s clothing:

  c. Amount used for beneficiary’s medical and dental care:
  d. Amount used for personal needs of the beneficiary:

  e. Amount used for support of beneficiary’s dependents:
  f. Amount used for other items: (show purpose for which funds were used in “REMARKS” section of
  this report)
8. Total amount used during the reporting period (Add 7a through 7f)

9. Balance remaining at the end of this period (item 6 minus 8)




                                                                                                                         Page 2 CM-623 (01/2024)
10. How is balance of the funds, shown in item #9, held, saved, or invested?
                                                              AMOUNT                   Name(s) that appears on each account.*
    Cash

    Checking Account

    Insured savings account

    U.S. Savings Bonds

    Other (Specify)
    * Specify who's name(s) appear on each account, i.e., "Your name for beneficiary", "Beneficiary's name by your name'', "Your
      name on-behalf-of (OBO) beneficiary", etc.
    NOTE: Benefits must be held in an account which shows that the money belongs to the beneficiary. If you are not sure whether the
          account you have established shows this ownership, you should consult your bank and, if necessary, change the account
          title appropriately.
11. If all benefits listed in item #6 of this report were held, saved, or invested, please explain how the beneficiary’s needs were met:




12. During this period, did the beneficiary have any benefits/income other than U.S. Department of Labor Black Lung Benefits?

    Yes         No     If yes, indicate the sources of the income:
 Source:                                                 Frequency of Payment                               Amount:

 Source:                                                 Frequency of Payment                               Amount:

 Source:                                                 Frequency of Payment                               Amount:

 Source:                                                 Frequency of Payment                               Amount:
13. Have you ever been convicted of a felony?
    Yes         No     If yes, explain below in remarks section.
 Remarks




If you misuse benefits received as a representative payee, you may be convicted of a feloney and fined under Title 18, U.S.C., or
imprisoned for not more than 5 years, or both. The court may also order restitution. 42 U.S.C. 408, incorporated by 30 U.S.C. 923(b), 940.

                                    I CERTIFY THAT THE INFORMATION I HAVE GIVEN ON THIS FORM IS TRUE
SIGNATURE OF PAYEE (if signed by mark (X), two witnesses must sign below)                     TELEPHONE NUMBER (include area code)


                                                                                                              Business
RELATIONSHIP TO BENEFICIARY OR TITLE                                  Date
                                                                                                                Home
            WITNESS SIGNATURES ARE REQUIRED ONLY IF THE PAYEE's SIGNATURE ABOVE HAS BEEN SIGNED BY MARK (X)
SIGNATURE OF WITNESS                  DATE:               SIGNATURE OF WITNESS                      DATE:




                                                                                                                         Page 3 CM-623 (01/2024)