OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Report of Changes That May Affect Your Black Lung Benefits

OMB 1240-0028 · DOL/OWCP.

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 2027-05-31 and is listed under ICR 202411-1240-002.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CM-929P Report of Changes That May Affect Your Black Lung BenefitsForm
Form CM-929 Report of Changes That May Affect Your Black Lung BenefitsForm
Form CM-929P Report of Changes That May Affect Your Black Lung BenefitsForm
Form CM-929 Report of Changes That May Affect Your Black Lung BenefitsForm
Form CM-929 Portal Report of changesForm
Form CM-929 Report of Changes That May Affect Your Black Lung BenefitsForm
Form CM-929P Report of Changes That May Affect Your Black Lung BenefitsForm
Form CM-929P Report of Changes That May Affect Your Black Lung BenefitsForm
Justification CM-929 & cm-929p Translated in Spanish.docxJustification for No Material/Nonsubstantive Change
screenshot of portal location for Online Contact Form.pngSupplementary Document
screenshot of portal location for Online Contact Form.png Supplementary Document
SS 1240-0028 929's 2024 4.25.24.docxSupporting Statement A
SS 1240-0028 929's 2024 4.25.24.docxSupporting Statement A
30 USC 901.docxSupplementary Document
DOL-OWCP-9.pdfSupplementary Document
DOL-OWCP-9.pdf Supplementary Document
725.533e.docxSupplementary Document
725.533e.docx Supplementary Document
725.513a.docxSupplementary Document
725.513a.docx Supplementary Document
System of Record Notice.pdfSupplementary Document
System of Record Notice.pdf Supplementary Document
Report of Changes That May Affect Your Black Lung Benefits Form
Report of Changes That May Affect Your Black Lung Benefits Form
Report of Changes That May Affect Your Black Lung Benefits Form
Report of Changes That May Affect Your Black Lung Benefits Form
Report of Changes That May Affect Your Black Lung Benefits Form
Report of Changes That May Affect Your Black Lung Benefits Form
Report of Changes That May Affect Your Black Lung Benefits Form
Report of Changes That May Affect Your Black Lung Benefits Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202411-1240-002 No material or nonsubstantive change to a currently approved collection 2024-12-03 Approved without change
202406-1240-001 No material or nonsubstantive change to a currently approved collection 2024-07-17 Approved without change
202311-1240-005 Revision of a currently approved collection 2024-03-29
202101-1240-001 Extension without change of a currently approved collection 2021-02-17 Approved without change
201710-1240-003 Revision of a currently approved collection 2017-12-31 Approved without change
201501-1240-002 No material or nonsubstantive change to a currently approved collection 2015-06-05 Approved without change
201405-1240-006 Revision of a currently approved collection 2014-09-25 Approved without change
201306-1240-007 No material or nonsubstantive change to a currently approved collection 2013-07-10 Approved without change
201207-1240-005 No material or nonsubstantive change to a currently approved collection 2012-08-08 Approved without change
201105-1240-005 Extension without change of a currently approved collection 2011-06-20 Approved without change
201003-1240-028 Revision of a currently approved collection 2010-03-12 Approved without change