Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor

OMB 1240-0011

The purpose of the CM-972 is to collect pertinent data to determine if the representative's services and the amounts charged can be paid under the Black Lung Benefits Act.

The latest form for Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor expires 2023-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CM-972 Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor Form
SS 1240-0011 CM-972_2023_OCIO MM.docx Supporting Statement A
DOL-OWCP-2, Office of Workers' Compensation, Black Lung Benefits Claim File.pdf Supplementary Document
Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor Form

All Historical Document Collections

202304-1240-002	Revision of a currently approved collection	2023-09-07
202001-1240-001 Approved without change	Extension without change of a currently approved collection	2020-05-12
201611-1240-001 Approved without change	Extension without change of a currently approved collection	2017-03-07
201309-1240-002 Approved without change	Revision of a currently approved collection	2014-01-30
201011-1240-001 Approved without change	Extension without change of a currently approved collection	2010-12-22
201003-1240-011 Approved without change	No material or nonsubstantive change to a currently approved collection	2010-03-12