OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

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

OMB 1240-0027 · DOL/OWCP.

OMB 1240-0027

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.

The latest form for Survivor's Form for Benefits Under the Black Lung Benefits Act expires 2026-10-31 and is listed under ICR 202402-1240-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits ActForm
Justification CM-912 Translated to Spanish.docx Justification for No Material/Nonsubstantive Change
Justification CM-912 Translated to Spanish.docx Justification for No Material/Nonsubstantive Change
SS 1240-0027 CM-912 2023_OCIO-Final.docxSupporting Statement A
SS 1240-0027 CM-912 2023_OCIO-Final.docxSupporting Statement A
Justification CM-912.docx Justification for No Material/Nonsubstantive Change
Justification CM-912.docx Justification for No Material/Nonsubstantive Change
DOL-OWCP-9.pdf Supplementary Document
DOL-OWCP-9.pdf Supplementary Document
725.212 to 725.225.docx Supplementary Document
725.212 to 725.225.docx Supplementary Document
CFR 725.304.pdf Supplementary Document
CFR 725.304.pdf Supplementary Document
System of Record Notice-DOL OWCP-2.pdf Supplementary Document
System of Record Notice-DOL OWCP-2.pdf Supplementary Document
Survivor's Form for Benefits Under the Black Lung Benefits Act Form
Survivor's Form for Benefits Under the Black Lung Benefits Act Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202402-1240-001 No material or nonsubstantive change to a currently approved collection 2024-03-13 Approved without change
202401-1240-010 No material or nonsubstantive change to a currently approved collection 2024-01-31 Approved without change
202304-1240-004 Revision of a currently approved collection 2023-09-07 Approved without change
201911-1240-004 Revision of a currently approved collection 2020-03-27 Approved without change
201607-1240-001 Extension without change of a currently approved collection 2016-12-28 Approved without change
201510-1240-003 No material or nonsubstantive change to a currently approved collection 2015-10-26 Approved without change
201306-1240-004 Extension without change of a currently approved collection 2013-10-25 Approved without change
201007-1240-002 Revision of a currently approved collection 2010-08-18 Approved without change
201003-1240-027 Extension without change of a currently approved collection 2010-03-12 Approved without change