Report of Changes That May Affect Your Black Lung Benefits

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0028 can be found here:

Documents and Forms

Document Name Document Type
Form CM-929 Report of Changes That May Affect Your Black Lung Benefits Form
CM-929 Report of Changes That May Affect Your Black Lung Benefi 929 updated form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-929 Report of Changes That May Affect Your Black Lung Benefi 929 updated form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-929P Report of Changes That May Affect Your Black Lung Benefi 929P updated form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-929P Report of Changes That May Affect Your Black Lung Benefi 929P updated form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Report of Changes That May Affect Your Black Lung Benefits	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.533(e) 20 CFR 725.513(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-929	Report of Changes That May Affect Your Black Lung Benefits	929 updated form.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-929P	Report of Changes That May Affect Your Black Lung Benefits	929P updated form.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-2 and DOL/OWCP-9	FR Citation: 81 FR 25765

Number of Respondents: 21,681	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	21,681	9,681	12,000
Annual IC Time Burden (Hours)	6,373	3,563	2,810
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.