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E-mail This PageDOL Form CM-912
| 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: | 1240-0027 |
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