SS 1240-0027 CM-912 2023_OCIO-Final

SS 1240-0027 CM-912 2023_OCIO-Final.docx

Survivor's Form for Benefits Under the Black Lung Benefits Act

OMB: 1240-0027

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1240-0027 can be found here:

2024-03-13 - No material or nonsubstantive change to a currently approved collection

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