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
| Document | Type |
|---|---|
 Form CM-912 Survivor’s Form for Benefits under the Black Lung Benefits Act (Large Print) | Form |
| Form CM-912 Survivor’s Form for Benefits under the Black Lung Benefits Act (Spanish) | Form |
 Form CM-912 Survivor’s Form for Benefits under the Black Lung Benefits Act | Form |
| SS 1240-0027 CM-912 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 |
| Survivor's Form for Benefits Under the Black Lung Benefits Act |
Form |
| Survivor's Form for Benefits Under the Black Lung Benefits Act |
Form |