Form CM-908 Notice of Termination, Suspension, Reduction, or Increas

U. S. Department of Labor

Notice of Termination,
Suspension, Reduction, or
Increase in Benefits Payments

Employment Standards Administration
Office of Workers’ Compensation Programs
Division of Coal Mine Workers’ Compensation

This report is required by the Black Lung Benefits Act (30 U.S.C. 901 et. seq.) and is mandatory (20CFR725.621). It is to be
completed in full and filed with the Office of Workers’ Compensation Programs within 16 days following the termination of
benefits, and immediately following the suspension, reduction or increase of benefits being paid under Title IV of the Federal
Mine Safety & Health Act of 1977, as amended to insure that correct benefits are paid. Failure to report can result in a civil
penalty of not more than $500 for each such failure or refusal.

Name and Address of Payee (Please Print) Include Zip Code

Distribution:
Copy 3 – Payee’s Copy
Copy 2 – Operator’s Copy
Copy 1 – Send To:
U. S. Department of Labor
ESA/OWCP/DCMWC Room N3464
200 Constitution Ave. NW
Washington, DC 20210
2. DOL Claim Number

1. Name of disabled or deceased miner

3. Name of coal mine operator

5. Action Taken:

… Terminated

OMB No. 1215-0064
Expires: 08/31/2009

4. Name of insurance carrier

Suspended

Reduced

Increased

6. Reasons why action taken:

a. Date of Last Payment
(mm/dd/yy)

b. Amount of Last Payment

c. Amount of Reduced/
Increased Payment

$

$

d. Date Benefits
Will Resume
(mm/dd/yy)

e. Date of this Notice
(mm/dd/yy)

7. Summary of Payments
a.

b.
Name of Payee

8. Signature of Person Issuing this notice

c.
From

To

d. Date Benefits
Will Resume

e. Amount Paid
Per Month

f.
Total

9. Title

10. Telephone Number
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 12
minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden, to the Division of Coal Mine Workers' Compensation, U. S.
Department of Labor, Room C-3520, 200 Constitution Avenue, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM
TO THIS OFFICE.
1 - District Director’s Copy
Form CM-908
Rev. Jan. 2009
Previous editions usable