View ESA-OWCP-DCMWC's Form 1215-0069 Online
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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