Report of Changes That May Affect Your Black Lung Benefits

NOTICE TO REVIEWER

Date: January 26, 2015

Request Type:  No material or non-substantive change to a currently approved collection

Employing Agency:  Office of Workers’ Compensation Programs/Division of Coal Mine Workers’ Compensation (DCMWC)

Form Number/Name:  CM-929 and CM-929P/Report of Changes That May Affect Your Black Lung Benefits – Report of Changes That May Affect Your Black Lung Benefits.

OMB/Expiration Date:  1240-0028, December 31, 2017

Justification:

DCMWC is seeking approval for forms CM-929 and CM-929P.

The CM-929 and CM-929P are used to help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Black Lung Disability Trust Fund. The CM-929 and CM-929P are completed by the beneficiary and representative payees to report factors that may affect the primary beneficiary’s benefits, including income, marital status, receipt of state workers' compensation, and dependents’ status.

Minor changes are being made to the CM-929 and CM-929P. The National Office telephone number is being added to the contact group of offices located on the instruction pages. On the CM-929P, question 8a the word “has” needs to replace the word “have”. On both CM-929 and CM-929P, question 6 the word “earning” needs to replace the word “earnings”.