Request for State or Federal Workers' Compensation Information

OMB 1240-0032

OWCP is requesting an address change to the Request for State or Federal Workers' Compensation Information (CM-905). DCMWC beneficiaries have their monthly benefits reduced dollar for dollar for other benefits that they receive attributable to their black lung disability from State or Federal workers' benefits. The CM-905 request the amount of those workers' compensation benefits.

The latest form for Request for State or Federal Workers' Compensation Information expires 2023-07-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CM-905 Request for State or Federal Workers' Compensation Information Form
1240-0032 Supporting Statement (CM-905) 5-18-23.docx Supporting Statement A
System of Record Notice-DOL OWCP-2.pdf Supplementary Document
20 CFR 725 535.pdf Supplementary Document
30 USC 924.pdf Supplementary Document
Request for State or Federal Workers' Compensation Information Form

202304-1240-008 Approved without change	Extension without change of a currently approved collection	2023-05-25
202008-1240-045 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-10-21
201911-1240-002 Approved without change	Revision of a currently approved collection	2020-02-27
201607-1240-002 Approved without change	Revision of a currently approved collection	2016-12-28
201306-1240-005 Approved without change	Extension without change of a currently approved collection	2013-10-24
201008-1240-001 Approved without change	Revision of a currently approved collection	2010-08-18
201003-1240-032 Approved without change	Extension without change of a currently approved collection	2010-03-12