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September 23, 2008    DOL Home > Find It! By Form > DOL Form   

DOL Form CM-912

View ESA-OWCP-DCMWC's Form 1215-0069 Online htm
Agency: ESA-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
OMB Expiration Date: Tuesday, August 31, 2010




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