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View ESA-OWCP-DCMWC's Form 1215-0084 Online 
| Agency: |
ESA-OWCP-DCMWC |
| Title: |
CM-929, Report of Changes That May Affect Your Black Lung Benefits |
| Form Description: |
CM-929, Report of Changes That May Affect Your Black Lung Benefits: To help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Black Lung Disability Trust Fund, the CM-929 is completed by the beneficiary to report factors that may affect his or her benefits, including income, marital status, receipt of state workers' compensation, and dependents’ status. |
| OMB Control Number: |
1215-0084 |
| OMB Expiration Date: |
Thursday, June 30, 2011
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