OMB No.: 1240-0020 

Expires: 05/31/2024

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. The report will be 

reviewed by the U. S. Department of Labor and is subject to verification. 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 an institution. You must also report the beneficiary’s receipt of any State Workers’ Compensation 

Benefits. If the person for whom you receive benefits is a student or is disabled, you must report any changes in school 

attendance or disability status. 

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.

U.S. DEPARTMENT OF LABOR 

Office of Workers' Compensation 

Division of Coal Mine Workers’ Compensation

PRIVACY ACT NOTICE 

The following statement is made in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. (1) Submission of this information 

is required by law (30 U.S.C. 922, and 20 CFR 725.513). (2) The information you furnish on this form may be used by other 

Government agencies or persons in handling matters relating, directly or indirectly, to the subject matter of the claim including 

potentially liable coal mine operators and their insurance carriers; contractors providing automated data processing services to 

the Department of Labor; representatives of the parties to the claim; and federal, state or local agencies in obtaining information 

about eligibility for benefits. (3) The Information may be disclosed to comply with Federal laws requiring the release of 

information from our records; or to conduct research and audit activities needed to assure the continuing integrity and 

improvement of the U.S. Department of Labor representative payee program. (4) 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 10 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, Room N-3464, 200 Constitution Avenue, N.W., 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.

800-347-3754 

800-347-3751 

800-366-4599 

800-347-3771

Johnstown, PA 

Parkersburg, WV 

Pikeville, KY 

Columbus, OH

800-347-3753 

800-347-3749 

800-366-4628 

800-366-4612

Greensburg, PA 

Charleston, WV 

Mt. Sterling, KY 

Denver, CO

BLACK LUNG DISTRICT OFFICE TOLL-FREE NUMBERS

REPRESENTATIVE PAYEE REPORT

CM-623S (05/2021)
REPRESENTATIVE PAYEE REPORT

DEPARTMENT OF LABOR 

USE ONLY

1. Have you lived in the same household as the beneficiary for the whole reporting period? If no, 

please explain in the comments section below.

2. How are you related to the beneficiary? (wife, son, daughter, etc)

3. Were all of the beneficiary's benefits, which you received during this reporting period, used or 

saved for the beneficiary?

4. a) Were benefits spent for the beneficiary on items other than for food, shelter, medical and 

personal needs?

b) If yes, briefly explain:

COMMENTS 

(This space is for any comments you may have concerning your position and responsibilities as representative payee):

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE INSTRUCTIONS ON THIS FORM AND THAT THE INFORMATION WHICH I HAVE 

PROVIDED ON THIS FORM IS TRUE.

Page 2 CM-623S (05/2021)

This report is for the period from : From: To:

Name and address of representative payee: Name and address of beneficiary:

DOL's Case ID Number:

Yes No

Yes No

Yes No

SIGNATURE OF PAYEE (if signed by mark (X), two witnesses must sign below)

RELATIONSHIP TO BENEFICIARY OR TITLE Date

TELEPHONE NUMBER (include area code)

Business Home

Date Date SIGNATURE OF WITNESS SIGNATURE OF WITNESS

WITNESS SIGNATURES ARE REQUIRED ONLY IF THE PAYEE's SIGNATURE ABOVE HAS BEEN SIGNED BY MARK (X)