Survivor's Form for Benefits Under the Black Lung Benefits Act

ICR 202402-1240-001

OMB: 1240-0027

Federal Form Document

Forms and Documents

Document Name	Status
Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits Act Form	Modified
Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits Act Form	Modified
Justification CM-912 Translated to Spanish.docx Justification for No Material/Nonsubstantive Change	2024-02-21
Justification CM-912 Translated to Spanish.docx Justification for No Material/Nonsubstantive Change	2024-02-21
SS 1240-0027 CM-912 2023_OCIO-Final.docx Supporting Statement A	2024-01-30
SS 1240-0027 CM-912 2023_OCIO-Final.docx Supporting Statement A	2024-01-30
Justification CM-912.docx Justification for No Material/Nonsubstantive Change	2024-01-30
Justification CM-912.docx Justification for No Material/Nonsubstantive Change	2024-01-30
DOL-OWCP-9.pdf Supplementary Document	2020-03-03
DOL-OWCP-9.pdf Supplementary Document	2020-03-03
725.212 to 725.225.docx Supplementary Document	2020-03-03
725.212 to 725.225.docx Supplementary Document	2020-03-03
CFR 725.304.pdf Supplementary Document	2019-11-26
CFR 725.304.pdf Supplementary Document	2019-11-26
System of Record Notice-DOL OWCP-2.pdf Supplementary Document	2019-11-26
System of Record Notice-DOL OWCP-2.pdf Supplementary Document	2019-11-26

IC Document Collections

IC ID	Document Title	Status
13721	Survivor's Form for Benefits Under the Black Lung Benefits Act Form	Modified
13721	Survivor's Form for Benefits Under the Black Lung Benefits Act Form	Modified