Survivor's Form for Benefits

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0027 can be found here:

Documents and Forms

Document Name Document Type
Form CM-912 Survivor's Form for Benefits Form
CM-912 Survivor's Form For Benefits Under The Black Lung Benefi cm-912.pdf www.dol.gov/esa/regs/compliance/owcp/cm-912.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survivor's Form for 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 410.221 20 CFR 725.304

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-912	Survivor's Form For Benefits Under The Black Lung Benefits Act	cm-912.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-912.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: ESA-6 (67 FR 16869) and ESA-30 (67 FR 16878)	FR Citation: 67 FR 16869

Number of Respondents: 1,750	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,750	-250	2,000
Annual IC Time Burden (Hours)	233	-34	267
Annual IC Cost Burden (Dollars)	681	-23	704

Documents for IC

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.