Information Collection

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

IC 13721 under ICR 202603-1240-004 · OMB 1240-0027.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-912 Survivor’s Form for Benefits under the Black Lung Benefits Act Survivor's Form for Benefits Under the Black Lung Benefits Act	Form
Form CM-912 Survivor’s Form for Benefits under the Black Lung Benefits Act (Spanish) Survivor's Form for Benefits Under the Black Lung Benefits Act	Form
Form CM-912 Survivor’s Form for Benefits under the Black Lung Benefits Act (Large Print) Survivor's Form for Benefits Under the Black Lung Benefits Act	Form
CM-912 Survivor’s Form for Benefits under the Black Lung Benefi CM-912 Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-912 Survivor’s Form for Benefits under the Black Lung Benefi cm-912_Spanish.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-912 Survivor’s Form for Benefits under the Black Lung Benefi CM-912 - Large Print form.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.304

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-912	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-912	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-912	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: DOL/OWCP-2 and DOL/OWCP-9

FR Citation: 67 FR 16869

Number of Respondents: 1,080

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,080	13	1,067
Annual IC Time Burden (Hours)	144	2	142
Annual IC Cost Burden (Dollars)	807	100	707

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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