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View ESA-OWCP-DCMWC's Form 1215-0166 Online 
| Agency: |
ESA-OWCP-DCMWC |
| Title: |
CM-910, Request To Be Selected As Payee |
| Form Description: |
CM-910, Request To Be Selected As Payee: If a black lung beneficiary is incapable of handling his or her affairs, the person or institution responsible for the beneficiary’s care is required to apply to receive the benefit payments on the beneficiary's behalf. The CM 910 is the form completed by a person wanting to be appointed as representative payee. |
| OMB Control Number: |
1215-0166 |
| OMB Expiration Date: |
Tuesday, March 31, 2009
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