Report of Changes That May Affect Your Black Lung Benefits

OMB 1240-0028

OMB 1240-0028

This information collection is necessary to help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Disability Trust Fund. It is also necessary to verify and update on a regular basis factors that affect a beneficiary's entitlement to benefits, including income, marital status, receipt of State Worker's Compensation, and dependent status.

The latest form for Report of Changes That May Affect Your Black Lung Benefits expires 2021-02-28 and can be found here.

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