OMB control number
Request for State or Federal Workers' Compensation Information
OMB 1240-0032 · DOL/OWCP.
OMB 1240-0032
The OWCP Division of Coal Mine Workers’ Compensation must collect information regarding the status of any worker's compensation inquiry for Federal or State claims regarding benefits received attributable to black lung disability. The OWCP Form CM-905 requests the amount of those workers' compensation benefits and is submitted from Federal or state agencies when the beneficiary has filed a claim for workers' compensation benefits due to pneumoconiosis or is receiving benefits that may need to be offset.
The latest form for Request for State or Federal Workers' Compensation Information expires 2029-08-31 and is listed under ICR 202601-1240-005.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CM-905 Request for State or Federal Compensation Information | Form |
| 1240-0032 Supporting Statement 2026.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 |
| Request for State or Federal Workers' Compensation Information |
Form |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202601-1240-005 | Extension without change of a currently approved collection | 2026-03-11 | ||
| 202304-1240-008 | Extension without change of a currently approved collection | 2023-05-25 | Approved without change | |
| 202008-1240-045 | No material or nonsubstantive change to a currently approved collection | 2020-10-21 | Approved without change | |
| 201911-1240-002 | Revision of a currently approved collection | 2020-02-27 | Approved without change | |
| 201607-1240-002 | Revision of a currently approved collection | 2016-12-28 | Approved without change | |
| 201306-1240-005 | Extension without change of a currently approved collection | 2013-10-24 | Approved without change | |
| 201008-1240-001 | Revision of a currently approved collection | 2010-08-18 | Approved without change | |
| 201003-1240-032 | Extension without change of a currently approved collection | 2010-03-12 | Approved without change |