Report of Changes That May Affect Your Black Lung Benefits

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CM-929 Report of Changes That May Affect Your Black Lung Benefits Form and Instruction
CM-929 Report of Changes That May Affect Your Black Lung Benefi CM-929 Instructions revised.pdf www.dol.gov/owcp/regs/compliance/cm-929.pdf Form and Instruction
CM-929P Report of Changes That May Affect Your Black Lung Benefi CM-929P Instructions revised.pdf www.dol.gov/owcp/regs/compliance/cm-929P.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CM-929	Report of Changes That May Affect Your Black Lung Benefits	CM-929 Instructions revised.pdf	http://www.dol.gov/owcp/regs/compliance/cm-929.pdf	Yes	No	Printable Only
Form and Instruction	CM-929P	Report of Changes That May Affect Your Black Lung Benefits	CM-929P Instructions revised.pdf	http://www.dol.gov/owcp/regs/compliance/cm-929P.pdf	Yes	No	Printable Only

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: 55,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	55,000	55,000
Annual IC Time Burden (Hours)	12,627	12,627
Annual IC Cost Burden (Dollars)	0	0

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.