Survivor's Form for Benefits Under the Black Lung Benefits Act

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-912 Survivor’s Form for Benefits under the Black Lung Benefits Act (Large Print)	Form	Modified	Available
Form CM-912 Survivor’s Form for Benefits under the Black Lung Benefits Act (Spanish)	Form	Modified	Available
Form CM-912 Survivor’s Form for Benefits under the Black Lung Benefits Act	Form	Modified	Available
SS 1240-0027 CM-912 Final.docx	Supporting Statement A	Uploaded 2026-06-16	Available
DOL-OWCP-9.pdf	Supplementary Document	Uploaded 2020-03-03	Available
725.212 to 725.225.docx	Supplementary Document	Uploaded 2020-03-03	Available
CFR 725.304.pdf	Supplementary Document	Uploaded 2019-11-26	Available
System of Record Notice-DOL OWCP-2.pdf	Supplementary Document	Uploaded 2019-11-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13721	Survivor's Form for Benefits Under the Black Lung Benefits Act	Form	Modified	Survivor’s Form for Benefits under the Black Lung Benefits Act (Large Print)
13721	Survivor's Form for Benefits Under the Black Lung Benefits Act	Form	Modified	Survivor’s Form for Benefits under the Black Lung Benefits Act (Spanish)
13721	Survivor's Form for Benefits Under the Black Lung Benefits Act	Form	Modified	Survivor’s Form for Benefits under the Black Lung Benefits Act

ICR Details

OMB Control No: 1240-0027	ICR Reference No: 202603-1240-004
Status: Received in OIRA	Previous ICR Reference No: 202402-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Survivor's Form for Benefits Under the Black Lung Benefits Act
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/29/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2026
Responses	1,080	1,067
Time Burden (Hours)	144	142
Cost Burden (Dollars)	807	707

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Abstract: The CM-912 is used to gather information from a beneficiary's survivor to determine if the survivor is entitled to benefits or the continuation of benefits.

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Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 18488	04/10/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 61456	09/29/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Survivor's Form for Benefits Under the Black Lung Benefits Act	CM-912, CM-912, CM-912	Survivor’s Form for Benefits under the Black Lung Benefits Act ,   Survivor’s Form for Benefits under the Black Lung Benefits Act (Spanish) ,   Survivor’s Form for Benefits under the Black Lung Benefits Act (Large Print)

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,080	1,067	0	0	13	0
Annual Time Burden (Hours)	144	142	0	0	2	0
Annual Cost Burden (Dollars)	807	707	0	0	100	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: EXPLANATION OF CHANGE TOTALS Respondents: The number of respondents increased from 1,067 to 1,080. The number of respondents increased due to an increase in claims filed. The following estimates also increased due to an increase in number of forms received/responses. Responses: Responses have increased from 1,067 to 1,080. Burden Hours: Burden hours have increased from 142 to 144. Costs: Annual burden costs have increased from $707.00 to $807.00.

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Annual Cost to Federal Government: $13,978

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/29/2026

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