Notice to Reviewer

NOTICE TO REVIEWER

Date: October 22, 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-912, Survivor’s Form For Benefits Under The Black Lung Benefits Act

OMB/Expiration Date:  1240-0027, December 31, 2016

Justification:

Minor changes have been made to CM-912 to provide clearer language for survivors completing this form.

Specifically, in the top block of CM-912, the first sentence was changed to read “If you are a survivor of a person who was receiving Federal black lung benefits, this form is a Survivor’s Notification of the Beneficiary’s Death.” The words “resulting from a claim filed before 1982” were removed.

Next, mid-point on the first page of CM-912, the bullet was removed before the words “If you are filing as a child, parent, brother or sister, go to Question 12.

Next, on the bottom of the first page of CM-912, the words “(Please Complete the Other Side of This Form)” were removed.

Finally, the “Notice” was added to the end of CM-912.