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

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 2023-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits Act Form
SS 1240-0027 CM-912 2023_OCIO-Final.docx Supporting Statement A
DOL-OWCP-9.pdf Supplementary Document
725.212 to 725.225.docx Supplementary Document
CFR 725.304.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

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