CM-912 - Survivor's Form For Benefits Under The Black Lung Benefits Act

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

U.S. Department of Labor
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

If you are a survivor of a person who was receiving Federal black lung benefits,
OMB No.: 1240-0027
this is a Survivor's Notification of the Beneficiary's Death. Otherwise, this is a
Expires: 10/31/2026
claim for survivor's benefits. This form is authorized by the Black Lung Benefits
Act (30 U.S.C. 901, et seq.) and by 20 C.F.R. 410.221 and 20 C.F.R. 725.304.
This information will be used to determine possible eligibility for and the amount of
benefits payable under the Act. Benefits may be payable to you, your children and
all children of the deceased miner. The information on this form is required to
(For Agency use
obtain a benefit. However, disclosure of your or the deceased miner's Social
only)
Security Number is voluntary; the failure to disclose such number will not result in
the denial of any right, benefit or privilege to which an individual may be entitled.
The Department of Labor conducts computer matches with the Social Security
Administration. Any information provided by applicants or recipients of financial
assistance or payments under Federal benefit programs may be subject to
verification through computer matches that the Department of Labor conducts with
these agencies.
1. Deceased Coal Miner's Name: First

Middle

Last

2. Deceased Coal Miner's Social Security Number:
3. COAL MINER'S BIRTH AND DEATH DATES (ATTACH DEATH CERTIFICATE, IF AVAILABLE)
a. Date of birth:

b. Date of death:

4. Your name: First
5. Your Social Security Number:

c. Was an autopsy performed?
Middle

Yes

No

Last

6. Your date of birth
Form CM-912 (Rev. May 2023)

7. Mailing Address (Number, Street, Apt. No., PO Box or Rural Route) 8. City, State, & Zip Code

9. Your email address:

10. Telephone Number (Include area code)

11. YOUR RELATIONSHIP TO THE MINER
Surviving Spouse

Dependent Child

Surviving Divorced Spouse

Dependent Parent or Sibling

12. Have you or the miner ever filed a State or Federal workers' compensation claim for
death or disability due to coal workers' pneumoconiosis (Black Lung) or any other lung
conditions?

Yes

No

13. Have you or any dependent of the miner ever received Federal Black Lung Benefits
under another miner's Social Security number? If yes, answer a & b.

Yes

No

a. Full Name of other miner for which you received Federal Black Lung benefits?
b. Social Security number of the other miner for which you received Federal Black Lung benefits?

14. Do you or the miner have any dependent unmarried children who are currently under
age 18; age 18 to age 23 and attending school; and/or age 18 or older and disabled?

Yes

No

15. Were you or the miner ever married to anyone else?

Yes

No

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Form CM-912 (Rev. May 2023)

16. The following events may affect your entitlement to Federal Black Lung Benefits. Do
you agree to notify the U.S. Department of Labor promptly if any of the events listed
below occur?

Yes

No

• You become entitled to receive any workers' compensation or occupational disease payments
because of the miner's disability or death due to pneumoconiosis (Black Lung Disease).
• You or a person receiving benefits marries, dies, or is adopted by someone else.
• You or a person receiving benefits becomes disabled or the existing disability ceases.
• You or a person receiving benefits divorces and/or receives support payments from previous spouse.
• A child (age 18-23) stops attending school, or in the case of the disabled child (age 18 or over), the
disabling condition improves.

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Form CM-912 (Rev. May 2023)

Note: Persons are not required to respond to this collection of information unless it displays a currently
valid OMB control number.
PRIVACY ACT NOTICE
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1)
the Black Lung Benefits Act (BLBA) (30 U.S.C. 901 et seq.), as amended, is administered by the Office of
Workers' Compensation Programs (OWCP) of the U.S. Department of Labor, which receives and
maintains personal information, relative to this application, on claimants and their immediate families; (2)
information obtained by OWCP will be used to determine eligibility for benefits payable under the BLBA;
(3) information may be given to other government agencies, coal mine operators potentially liable for
payment of the claim or to the insurance carrier or other entity which secured the operator's compensation
liability, contractors providing automated data processing services to the Department of Labor; and
representatives of the parties to the claim; (4) information may be given to physicians or other medical
service providers for use in providing treatment, making evaluations and for other purposes relating to the
medical management of the claim; (5) information may be given to the Department of Labor's Office of
Administrative Law Judges, or other person, board or organization, which is authorized or required to
render decisions with respect to the claim or other matters arising in connection with the claim; (6)
information may be given to Federal, state or local agencies for law enforcement purposes, to obtain
information relevant to a decision under the BLBA, to determine whether benefits are being or have been
paid properly, and where appropriate, to pursue administrative offset and/or debt collection actions
required or permitted by law; (7) disclosure of the claimant's or deceased miner's Social Security Number
(SSN) or tax identifying number (TIN) on this form is voluntary, and the SSN and/or TIN and other
information maintained by the OWCP may be used for identification and for other purposes authorized by
law; (8) failure to disclose all requested information, may delay the processing of this claim or the payment
of benefits, or may result in an unfavorable decision or reduced level of benefits; and (9) this information is
included in a System of Records, DOL/OWCP-2 published at 81 Federal Register 25765, 25858 (April 29,
2016) or as updated and republished.
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Form CM-912 (Rev. May 2023)

SIGNATURE OF APPLICANT
I hereby certify that the information given by me on and in connection with this form is true and correct to
the best of my knowledge and belief. I am also fully aware that any person who willfully makes any false
or misleading statement or representation for the purpose of obtaining any benefit or payment under this
title shall be guilty of a misdemeanor under 30 USC 941 and, on conviction, subject to a fine of not more
than $1,000.00, or by imprisonment for not more than one year, or both. I authorize any physician,
hospital, agency, employer or other organization (including the Social Security Administration) to disclose
any medical records, or other information to the Department of Labor, Office of Workers’ Compensation
Programs. Furthermore, I authorize the Department of Labor, Office of Workers’ Compensation Programs
to disclose any medical or other information about the decision in your Black Lung Benefits claim to the
Workers’ Compensation, Unemployment Compensation, or Disability Insurance agency of my State to use
in connection with any claim with another agency.
17. Signature in ink (First, Middle, Last)

18. Date

Witnesses are required only if this application has been signed by mark (X) above. If signed by mark (X),
two witnesses to the signing who know the applicant must sign below, giving their full address.
19. Signature of Witness

20. Signature of Witness

21. Address of Witness

22. Address of Witness

23. City, State, ZIP Code

24. City, State, ZIP Code

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Form CM-912 (Rev. May 2023)

Public Burden Statement
Public reporting for this collection of information is estimated to average 8 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to the U.S. Department of Labor, Division of Coal Mine Workers' Compensation, Room
C-3520, 200 Constitution Avenue, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED
FORM TO THIS OFFICE.
Notice
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law
gives you the right to receive help from OWCP in the form of communication assistance, accommodation
and modification to aid you in the claims process. For example, we will provide you with copies of
documents in alternate formats, communication services such as sign language interpretation, or other
kinds of adjustments or changes to account for the limitations of your disability. Please contact our office
or the claims staff to ask for assistance.
TWO FILING OPTIONS:
1. To file electronically, submit the completed form and accompanying documentation to the C.O.A.L.
Mine Portal:
https://coalmine.dol.gov
2. To file by mail submit the 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
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Form CM-912 (Rev. May 2023)