Report of Changes That May Affect Your Black Lung Benefits

ICR 202311-1240-005

OMB: 1240-0028

Federal Form Document

Forms and Documents

Document Name	Status
Form CM-929 Report of Changes That May Affect Your Black Lung Benefits Form	Modified
SS 1240-0028 929's 2024_MN-MM (002)_MN-MM-RB.docx Supporting Statement A	2024-02-29
30 USC 901.docx Supplementary Document	2021-01-07
DOL-OWCP-9.pdf Supplementary Document	2021-01-07
725.533e.docx Supplementary Document	2021-01-07
725.513a.docx Supplementary Document	2021-01-07
System of Record Notice.pdf Supplementary Document	2017-11-22

IC Document Collections

IC ID	Document Title	Status
13756	Report of Changes That May Affect Your Black Lung Benefits Form	Modified