DOL Form CM-912

View OWCP-DCMWC's Form CM-912 Online htm

Agency:

OWCP-DCMWC

Title:

CM-912, Survivor's Form For Benefits Under The Black Lung Benefits Act

Form Description:

CM-912, Survivor's Form For Benefits Under The Black Lung Benefits Act: This form is an application for benefits or continuation of benefits by survivors. A surviving spouse, child, parent or sibling must complete this form and send it to the black lung district office. A local social security office or black lung district office can help in the completion of this form.

OMB Control Number:

1215-0069