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

IC 13721 under ICR 202402-1240-001 · OMB 1240-0027.

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Survivor's Form for Benefits Under the Black Lung Benefits Act
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 725.304

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 _Spanish-Final.docx https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Yes Yes Fillable Printable
Form CM-912 Survivor's Form For Benefits Under The Black Lung Benefits Act CM-912 Form.docx https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Yes Yes Fillable Printable

Income Security Survivor Compensation

DOL/OWCP-2 and DOL/OWCP-9  67 FR 16869

1,067 0
   
Individuals or Households
 
   4 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,067 0 0 0 0 1,067
Annual IC Time Burden (Hours) 142 0 0 0 0 142
Annual IC Cost Burden (Dollars) 707 0 0 0 0 707

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