Application For Self-insurance Under The Black Lung Benefits Act

NON- SUBSTANTIVE CHANGE REQUEST FOR THE APPLICATION FOR SELF-INSURANCE UNDER THE BLACK LUNG BENEFITS ACT FORMS CM-2017, CM-2017a, & CM-2017b

OMB CONTROL NO. 1240-0057 (January 2024)

DCMWC is requesting a non-substantive change to the recently approved collection of information contained in the “Application for Self-Insurance Under the Black Lung Benefits Act” to change the suite number of DCMWC’s mailing address.

DCMWC seeks to revise the recently approved CM-2017, CM-2017a, & CM-2017b as follows:

CM-2017

• “Under Public Burden Statement” change address to 200 Constitution Avenue, N.W., Suite C3520-DCMWC, Washington, D.C. 20210

CM-2017a

• “Under Public Burden Statement” change address to 200 Constitution Avenue, N.W., Suite C3520-DCMWC, Washington, D.C. 20210

• “Submission”: change address to 200 Constitution Avenue, N.W., Suite C3520-DCMWC, Washington, D.C. 20210 ATTN: Responsible Operator Section

CM-2017b

• “Under Public Burden Statement” change address to 200 Constitution Avenue, N.W., Suite C3520-DCMWC, Washington, D.C. 20210

• “Submission”: change address to 200 Constitution Avenue, N.W., Suite C3520-DCMWC, Washington, D.C. 20210 ATTN: Responsible Operator Section

These changes request do not affect the burden hours. The burden hours remain the same.

The revised forms are attached to this change request.