Information Collection Request
Survivor's Form for Benefits Under the Black Lung Benefits Act
ICR 202401-1240-010 · OMB 1240-0027 · Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0027 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits Act |
Form | Modified | Available |
| Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits Act |
Form | Modified | Repair queued |
 SS 1240-0027 CM-912 2023_OCIO-Final.docx |
Supporting Statement A | Uploaded 2024-01-30 | Available |
| SS 1240-0027 CM-912 2023_OCIO-Final.docx |
Supporting Statement A | Uploaded 2024-01-30 | Repair queued |
| Justification CM-912.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2024-01-30 | Available |
| Justification CM-912.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2024-01-30 | Repair queued |
 DOL-OWCP-9.pdf |
Supplementary Document | Uploaded 2020-03-03 | Available |
| DOL-OWCP-9.pdf |
Supplementary Document | Uploaded 2020-03-03 | Repair queued |
| 725.212 to 725.225.docx |
Supplementary Document | Uploaded 2020-03-03 | Available |
| 725.212 to 725.225.docx |
Supplementary Document | Uploaded 2020-03-03 | Repair queued |
| CFR 725.304.pdf |
Supplementary Document | Uploaded 2019-11-26 | Available |
| CFR 725.304.pdf |
Supplementary Document | Uploaded 2019-11-26 | Repair queued |
| System of Record Notice-DOL OWCP-2.pdf |
Supplementary Document | Uploaded 2019-11-26 | Available |
| System of Record Notice-DOL OWCP-2.pdf |
Supplementary Document | Uploaded 2019-11-26 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 13721 |  Survivor's Form for Benefits Under the Black Lung Benefits Act |
Form | Modified | |
| 13721 | Survivor's Form for Benefits Under the Black Lung Benefits Act |
Form | Modified |
ICR Details
| Status | Active |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0027 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202304-1240-004 |
| Date Submitted to OIRA | 2024-01-31 |
| Requested Expiration Date | 1969-12-31 |