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 can be found here.

Latest Forms, Documents, and Supporting Material
Document
Name
Form
Justification for No Material/Nonsubstantive Change
Supplementary Document
Supporting Statement A
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
Supplementary Document
All Historical Document Collections
Approved without change
 No material or nonsubstantive change to a currently approved collection 2024-12-03
Approved without change
 No material or nonsubstantive change to a currently approved collection 2024-07-17
Revision of a currently approved collection 2024-03-29
Approved without change
 Extension without change of a currently approved collection 2021-02-17
Approved without change
 Revision of a currently approved collection 2017-12-31
Approved without change
 No material or nonsubstantive change to a currently approved collection 2015-06-05
Approved without change
 Revision of a currently approved collection 2014-09-25
Approved without change
 No material or nonsubstantive change to a currently approved collection 2013-07-10
Approved without change
 No material or nonsubstantive change to a currently approved collection 2012-08-08
Approved without change
 Extension without change of a currently approved collection 2011-06-20
Approved without change
 Revision of a currently approved collection 2010-03-12