Information Collection

Report of Changes That May Affect Your Black Lung Benefits

IC 13756 under ICR 201003-1240-028 · OMB 1240-0028.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0028 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-929 Report of Changes That May Affect Your Black Lung Benefits	Form
CM-929 Report of Changes That May Affect Your Black Lung Benefi CM-929 4-2-2008.doc www.dol.gov/esa/regs/compliance/owcp/cm-929.pdf	Form
CM-929P Report of Changes That May Affect Your Black Lung Benefi CM-929P 4-10-2008.doc www.dol.gov/libraryforms/FormsByNum.asp	Form and Instruction

IC Title:

Report of Changes That May Affect Your Black Lung Benefits

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.513

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-929	Report of Changes That May Affect Your Black Lung Benefits	CM-929 4-2-2008.doc	http://www.dol.gov/esa/regs/compliance/owcp/cm-929.pdf	Yes	No	Fillable Printable
Form and Instruction	CM-929P	Report of Changes That May Affect Your Black Lung Benefits	CM-929P 4-10-2008.doc	http://www.dol.gov/libraryforms/FormsByNum.asp	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/ESA-6

FR Citation: 67 FR 16869

Number of Respondents: 70,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	70,000	19,000	51,000
Annual IC Time Burden (Hours)	15,269	10,764	4,505
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.