CM-911 Miner's Claim for Benefits Under the Black Lung Benefits

Miner's Claim for Benefits Under the Black Lung Benefits Act and Employment History

CM-911 Feb 2016

1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History

OMB: 1240-0038

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1240-0038 can be found here:

2024-03-13 - No material or nonsubstantive change to a currently approved collection
2024-01-31 - No material or nonsubstantive change to a currently approved collection

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File Type	application/pdf
File Title	DOL-ESA Forms
Subject	cm-911
Author	Richard Maley
File Modified	2016-02-10
File Created	2015-02-02