Survivor’s Form For Benefits Under The Black Lung Benefits Act

NON- SUBSTANTIVE CHANGE REQUEST FOR SURVIVOR’S FORM FOR BENEFITS UNDER THE BLACK LUNG BENEFITS ACT CM-912

OMB CONTROL NO. 1240-0027 (January 2024)

DCMWC is requesting a non-substantive change to the recently approved collection of information contained in “Survivor's Form for Benefits Under the Black Lung Benefits Act” to update the URL of the coal mine portal and add our toll-free telephone number in the CM-912 Form.

DCMWC seeks to revise the recently approved CM-912 as follows:

TWO FILING OPTIONS:

1. To file electronically, submit completed form and accompanying documentation to the C.O.A.L. Mine Portal:

https://coalmine.dol.gov

2. To file by mail submit completed form and accompanying documentation to:

U.S. Department of Labor OWCP/DCMWC

Central Mail Room

PO Box 8307

London, KY 40742-8307

For further information call TOLL FREE: 1-800-347-2502

This change request does not affect the burden hours. The burden hours remain the same.

The revised form is attached to this change request.