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

OMB 1240-0027

OMB 1240-0027

The CM-912 is used to gather information from a beneficiary's survivor to determine if the survivor is entitled to benefits or the continuation of benefits.

The latest form for Survivor's Form for Benefits Under the Black Lung Benefits Act expires 2023-10-31 and can be found here.

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