Form CM-912 Survivor's Form For Benefits Under The Black Lung Benefi

Survivor's Form For Benefits Under
The Black Lung Benefits Act
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U.S. Department of Labor
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

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If you are a survivor of a person who was receiving Federal black lung benefits resulting from a claim filed before
1982, this form is a Survivor's Notification of the Beneficiary's Death. Otherwise, this is a claim for survivor's benefits.
This form is authorized by the Black Lung Benefits Act (30 U.S.C. 901, et seq.) and by 20 C.F.R. 410.221 and 20 C.F.R.
725.304. This information will be used to determine possible eligibility for and the amount of benefits payable under
the Act. Benefits may be payable to you, your children and all children of the deceased miner. The information on this
form is required to obtain a benefit. However, disclosure of your or the deceased miner's Social Security Number
is voluntary; the failure to disclose such number will not result in the denial of any right, benefit or privilege to which
an individual may be entitled.

OMB No.: 1240-0027
Expires: 10/31/2013
(For Agency use only)

(First, Middle, Last)

1.

Deceased Coal
Miner's Name:

2.

Deceased Coal Miner's Social Security Number:

3.

COAL MINER's BIRTH AND DEATH DATES (ATTACH DEATH CERTIFICATE, IF AVAILABLE)
Date of death:

Date of birth:
First

4.

Your name:

5.

Your Social Security Number:

7.

SHOW YOUR RELATIONSHIP TO THE MINER

Middle

Autopsy?

Yes

No

Last

6. Your date of birth:

[ ] Surviving Spouse (wife or Husband)

[ ]Dependent Child

[ ] Surviving Divorced Spouse

[ ] Dependent Parent, Brother or Sister

8.

Have you or the miner ever filed a State or Federal workers' compensation claim for death or
disability due to coal workers' pneumoconiosis (Black Lung) or any other lung conditions?

9.

Have you or any dependent of the miner ever received Federal Black Lung Benefits under

another miner's Social Security number?

Yes

No

Yes

No

• IF YOU ARE FILING AS A CHILD, PARENT, BROTHER OR SISTER, GO TO QUESTION 12.
10. Do you or the miner have any dependent children under age 18, age 18 to 23 and attending
school, 18 or older and disabled?

Yes

No

11. Were you or the miner ever married to anyone else at anytime?

Yes

No

Yes

No

Yes

No

12. Do you authorize any physician, hospital, agency or other organization (including Social
Security Administration) to disclose to the Department of Labor any medical records or
information important to your claim?
13. The following events may affect your entitlement to Federal Black Lung Benefits. Do you
agree to notify the U.S. Department of Labor promptly if any of the events listed below occur?

• You become entitled to receive any workers' compensation or occupational disease payments because of the miner's
disability or death due to pneumoconiosis (Black Lung Disease).
• A person receiving benefits marries, dies, or is adopted by someone else, becomes disabled or the existing disability
ceases, or if divorced, receives support payments from previous spouse.
• A child (age 18-23) stops attending school, or in the case of the disabled child (age 18 or over), the disabling condition
improves.

(PLEASE COMPLETE THE OTHER SIDE OF THIS FORM)
Form CM-912
Rev. Oct 1998

PRIVACY ACT NOTICE
In accordance with the Privacy Act of 1974 (5 U.S.C. 552a), as amended, you are hereby notified that: (1) the Black Lung Benefits Act (BLBA)
(30 U.S.C.901 et seq.), as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of
Labor, which receives and maintains personal information, relative to this application, on claimants and their immediate families;
(2) information obtained by OWCP will be used to determine eligibility for benefits payable under the BLBA; (3) information may be
given to coal mine.operators potentially liable for payment of the claim or to the insurance carrier or other entity which secured the operator's
compensation liability; (4) information may be given to physicians or other medical service providers for use in providing treatment, making
evaluations and for other purposes relating to the medical management of the claim; (5) information may be given to the Department of
Labor's Office of Administrative Law Judges, or other person, board or organization, which is authorized or required to render decisions with
respect to the claim or other matters arising in connection with the claim; (6) information may be given to Federal, state or local agencies for
law enforcement purposes, to obtain information relevant to a decision under the BLBA, to determine whether benefits are being or have been
paid properly, and where appropriate, to pursue administrative offset and/or debt collection actions required or permitted by law;
(7) disclosure of the claimant's or deceased miner's Social Security Number (SSN) or tax identifying number (TIN) on this form is voluntary,
and the SSN and/or TIN and other information maintained by the OWCP may be used for identification and for other purposes authorized by
law; (8) failure to disclose all requested information, other than the SSN or TIN, may delay the processing of this claim or the payment of
benefits or may result in an unfavorable decision or reduced level of benefits.
COMPUTER MATCHING PROGRAM. The Department of Labor conducts computer matches with the Social Security
Administration. Any information provided by applicants for and recipients of financial assistance or payments under
Federal benefit programs may be subject to verification through computer matches which the Department of Labor
conducts with the Social Security Administration.
SIGNATURE OF APPLICANT
I hereby certify that the information given by me on and in connection with this form is true and correct to the
best of my knowledge and belief. I am also fully aware that any person who willfully makes any false or
misleading statement or representation for the purpose of obtaining any benefit or payment under this title shall be
guilty of a misdemeanor and on conviction thereof shall be punished by a fine of not more than $1,000, or by
imprisonment for not more than one year or both.
Signature in ink (First, Middle, Last)

Date

Mailing Address (Number, Street, Apt. No., PO Box, Rural Route)

County you live in

City, State, ZIP Code

Area Code and Telephone Number

Witnesses are required only if this application has been signed by mark (X) above. If signed by mark (X), two witnesses
to the signing who know the applicant must sign below, giving their full address.
Signature of Witness

Signature of Witness

Address of Witness

Address of Witness

City, State, ZIP Code

City, State, ZIP Code

Public reporting for this collection of information is estimated to average 8 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 U. S. Department of Labor, Division of Coal
Mine Workers' Compensation, 200 Constitution Avenue, Room N-3464, Washington, DC 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.