Report of Changes that may affect your Black Lung Benefits

U.S. DEPARTMENT OF LABOR

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Division of Coal Mine Workers' Compensation

PLEASE KEEP THIS FOR YOUR RECORDS AND FOR FUTURE REFERENCE.
Instructions
Complete, sign, date, and return the enclosed REPORT OF CHANGES form, in the envelope provided,
to your Black Lung District Office within 30 days of receipt. The form contains information the Department of
Labor has concerning the beneficiary’s Black Lung benefits claim. If the information is not correct, please
supply the correct information in the spaces provided on the form.
Failure to return this form could result in the suspension or termination of benefits.
If you have any questions about this form, please call your Black Lung Office at the toll-free 800-number
appearing at the top of this page.
REPORTING REQUIREMENTS
The law requires you to report immediately any of the following events regarding the beneficiary:
1. Marriage
2. Divorce
3. Birth or adoption of dependent child
4. Marriage of dependent child
5. Death of spouse/child
6. Disability of child (any age)

7. Change in school attendance of dependent
children age 18 or older
8. Return to work
9. Increased earnings
10. Filing for or receipt of State of other Federal
Workers’ Compensation Benefits

These events could affect the amount of the beneficiary’s monthly check. If not reported timely and the
beneficiary is overpaid, you may have to pay back the benefits that you incorrectly received. If the information
on the form is not correct, you must correct that information.
Medical Benefit Information
If the beneficiary is a miner, the Black Lung Disability Trust Fund is responsible for payment of his black
lung-related medical expenses. However, if the beneficiary also receives benefits for a black lung condition
from a state or another Federal workers’ compensation program, the black lung-related medical expenses may
be paid, partially or totally, by the party who pays those benefits.
Unless another party is responsible for payment of the black lung-related medical expenses, the miner should
continue to use the Black Lung Identification Card (the red and white card) when receiving medical treatment for
his/her black lung condition. Examples of black lung-related medical services are: hospitalizations, doctor’s
office visits, medically prescribed drugs, certain types of medical equipment (such as oxygen machines), home
nursing services, pulmonary rehabilitation, and the reasonable cost for travel to and from a medical facility for
the treatment of the black lung condition.
If you have any questions concerning the medical coverage for the miner’s black lung condition, you should
contact your Black Lung District Office at the toll-free 800-number appearing at the top left corner of this page.

Computer Matching Program
The Department of Labor will match this information by computer with the Social Security Administration. Any
information provided by applicants for and recipients of financial assistance or payments under Federal benefits
programs may be subject to verification by Department of Labor computer matches with these agencies.
PAPERWORK / PRIVACY ACT NOTICE
The following statement is made in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a).
This report is authorized by law (30 USC 922 section 20 CFR 725.513). Your cooperation is needed to insure
that Black Lung benefits are being received in the correct amount. The information you furnish on this form
may be routinely disclosed without your consent to another person or government agency for purposes such
as (1) to comply with Federal laws requiring the release of information from our records; or (2) to conduct
research and audit activities needed to assure the continuing integrity and improvement of the U.S.
Department of Labor representative payee program. Other routine disclosures of information are listed in the
Federal Register, which will be made available upon request.
PUBLIC BURDEN STATEMENT
We estimate that it will take an average of 5 - 8 minutes per response to complete this collection of
information, including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. If you have any
comments regarding these estimates or any other aspect of this collection of information, including
suggestions for reducing this burden, send them to the U.S. Department of Labor, Division of Coal Mine
Workers’ Compensation, Room N-3464, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT
SEND THE COMPLETED FORM TO THIS OFFICE
Note: Persons are not required to respond to this collection of information unless it displays a currently valid
OMB control number.

U.S. Department of Labor
OWCP/DCMWC

Report of Changes That May Affect
Your Black Lung Benefits

200 Constitution Ave. NW
Washington, DC 20210

U.S. Department of Labor

Beneficiary’s Name

OMB No.: 1240-0028
Expires: xx-xx-xxxxx

Telephone No.

IMPORTANT NOTICE: This ANNUAL REPORT OF CHANGES must be completed, signed,
dated, and returned within thirty (30) days of receipt. Below, you will find information about your Federal Black
Lung Benefits. If the information is not correct or if you have changes to report, enter the new information in the
space provided below each statement or question.
1. If you have changed your address or telephone number, please provide the new information below. Even
if you receive your black lung benefits by direct deposit, we must have your correct address so we can
send letters and other important information to you.
ADDRESS: ________________________________________________________________________
_________________________________________________________________________________
________________________________________ TELEPHONE NUMBER:____________________
2. Please list below the name and telephone number of a relative or close friend whom you would wish us to
contact if you were unable to call or write us regarding your black lung benefits.
_______________________________________________________________
3. Your monthly black lung benefit payment is $

.

4. Check the proper box below regarding any changes to your marital status in the last year.
□ No change in the last year (If you check this block, please proceed to question #5)
□ Death of Spouse – Date of death _________________
□ Separation from Spouse – Date of Separation ______________
□ Divorce – Date of Divorce _________________
□ Marriage – Date of Marriage ___________ Name of Spouse __________
Social Security Number of Spouse_________________
5. During the last twelve months, if any children who receive FEDERAL BLACK LUNG benefits along with
you had a change in their condition(s), please provide the following information.
Child’s name

Date of
Birth

Date of
Marriage

Date School
Attendance Ended

Date Disability
Began/Ended

Date of Death

CM-929 (Rev. 11-07)

6. In addition to BLACK LUNG Benefits, if you also receive payment from another FEDERAL or a STATE
Workers’ Compensation program, please provide the following information.
Amount received from other Federal or State Compensation program: $______________;
How often do you receive this benefit? □ WEEKLY

□ EVERY TWO WEEKS

□ MONTHLY

7. FOR COAL MINERS UNDER AGE 65, AND DISABLED ADULT CHILDREN, ONLY: If you are working
and earning money from any type of employment, please give us the following information.
Employer: _________________________________________
Total earnings last calendar year: $___________
Estimated earnings for this year: $____________
THIS FORM MUST BE SIGNED AND DATED.
I CERTIFY THAT ALL OF THE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.
If you conceal or fail to disclose a reporting event with an intent to obtain benefits fraudulently, either in
a greater amount or when no payment is authorized, you may be fined, imprisoned, or both, as
provided in 30 U.S.C. 941.
______________________________________ ________________________
Beneficiary’s Signature or “Mark”
Date
Witness signatures are required only if the payee’s signature above has been signed by mark (X).
______________________________________
Witness’ Signature
Date

_____________________________________
Witness’ Signature
Date

Reason beneficiary did not sign or make mark:
________________________________________________________________________________
________________________________________________________________________________
COMMENTS/ADDITIONAL INFORMATION:

CM-929, page 2 (Rev. 11-07)