Information Collection

Survivor's Form for Benefits Under the Black Lung Benefits Act

IC 13721 under ICR 201510-1240-003 · OMB 1240-0027.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0027 can be found here:

Documents and Forms

Document Name Document Type
Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits Act Form
CM-912 Survivor's Form For Benefits Under The Black Lung Benefi cm-912_working.pdf www.dol.gov/esa/regs/compliance/owcp/cm-912.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survivor's Form for Benefits Under the Black Lung Benefits Act	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.304 20 CFR 410.221

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-912	Survivor's Form For Benefits Under The Black Lung Benefits Act	cm-912_working.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-912.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: ESA-6 (67 FR 16869) and ESA-30 (67 FR 16878)	FR Citation: 67 FR 16869

Number of Respondents: 1,100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,100	1,100
Annual IC Time Burden (Hours)	147	147
Annual IC Cost Burden (Dollars)	441	441

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.