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

NON- SUBSTANTIVE CHANGE REQUEST FOR SURVIVOR’S FORM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT CM-912

OMB CONTROL NO. 1240-0027 (February 2024)

DCMWC is requesting a non-substantive change to the recently approved collection of information contained in “Survivor's Form for Benefits Under the Black Lung Benefits Act” CM-912 Form. Our program considered the translation of this vital form to Spanish, to strengthen customer service experience, following Executive Order 14058, Transforming Federal Customer Experience and Service Delivery to Rebuild Trust in Government.

DCMWC seeks to revise the recently approved CM-912 as follows:

The currently approved CM-912 was translated entirely to Spanish.

This change request does not affect the burden hours. The burden hours remain the same.

The revised form is attached to this change request.