Request for State or Federal Workers' Compensation Information

OMB 1240-0032

OMB 1240-0032

OWCP is requesting an address change to the Request for State or Federal Workers' Compensation Information (CM-905). DCMWC beneficiaries have their monthly benefits reduced dollar for dollar for other benefits that they receive attributable to their black lung disability from State or Federal workers' benefits. The CM-905 request the amount of those workers' compensation benefits.

The latest form for Request for State or Federal Workers' Compensation Information expires 2023-07-31 and can be found here.


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