Information Collection Request
Report of Changes That May Affect Your Black Lung Benefits
ICR 202311-1240-005 · OMB 1240-0028 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0028 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CM-929 Report of Changes That May Affect Your Black Lung Benefits |
Form | Modified | Repair queued |
 SS 1240-0028 929's 2024_MN-MM (002)_MN-MM-RB.docx |
Supporting Statement A | Uploaded 2024-02-29 | Repair queued |
| 30 USC 901.docx |
Supplementary Document | Uploaded 2021-01-07 | Repair queued |
 DOL-OWCP-9.pdf |
Supplementary Document | Uploaded 2021-01-07 | Repair queued |
| 725.533e.docx |
Supplementary Document | Uploaded 2021-01-07 | Repair queued |
| 725.513a.docx |
Supplementary Document | Uploaded 2021-01-07 | Repair queued |
| System of Record Notice.pdf |
Supplementary Document | Uploaded 2017-11-22 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 13756 |  Report of Changes That May Affect Your Black Lung Benefits |
Form | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0028 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 202101-1240-001 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |