U.S. DEPARTMENT OF LABOR 

Office of Workers' Compensation 

Division of Coal Mine Workers’ Compensation

Complete, sign, date, and return the enclosed REPORT OF CHANGES form, within 30 days of receipt. 

Instructions on how to submit the form online or by mail are on page 5. The form contains information the 

Department of Labor has concerning the beneficiary’s black lung benefits claim. If the information is not 

correct, please supply the correct information in the spaces provided on the form. Failure to return this form 

could result in the suspension or termination of benefits. 

 

If you have any questions about this form, please call your nearest black lung office at the toll-free 800- 

number shown in the list on the following page. 

 

REPORTING REQUIREMENTS 

The law requires you to report immediately any of the following events regarding the beneficiary:

PLEASE KEEP THIS FOR YOUR RECORDS AND FOR FUTURE REFERENCE. 

 

Instructions For CM-929P 

1. Marriage 

2. Divorce 

3. Birth or adoption of dependent child 

4. Marriage of dependent child 

5. Death of spouse/child 

6. Disability of child (any age)

7. Change in school attendance of dependent 

children age 18 or older 

8. Return to work 

9. Increased earnings 

10. Filing for or receipt of state or other federal 

workers’ compensation benefits 

These events could affect the amount of the beneficiary’s monthly check. If not reported timely and the 

beneficiary is overpaid, you may have to pay back the benefits that you incorrectly received. If the information 

on the form is not correct, you must correct that information. 

Your Responsibility as a Representative Payee

Your job as a representative payee is to use the Black Lung benefits you receive for the personal care and 

well-being of the beneficiary. You must keep yourself informed of the beneficiary’s needs so you can decide 

how the benefits should be used. You must contact the U.S. Department of Labor when the beneficiary 

changes residence or if you no longer exercise responsibility for the care and welfare of the beneficiary. You 

must report the beneficiary’s death, marriage, adoption, employment, or release from a hospital or institution. 

You must also report the beneficiary’s receipt of any state workers’ compensation benefits and changes in 

school attendance or disability status, if the person for whom you receive benefits is a student or disabled. 

Whoever, having received a payment for the use and benefit of another person, knowingly and willfully uses 

such payment for other than the use and benefit of the person for whom it is received, is subject to a fine, or 

imprisonment or both. Benefits shall be held in an interest bearing account which shows that the money 

belongs to the beneficiary, i.e., “Your name for beneficiary”, “Beneficiary’s name by your name”, “Your name 

on-behalf-of (OBO) beneficiary,” etc. If you are not sure whether the account you have established shows this 

ownership, you should consult your bank and, if necessary, change the account title appropriately. 

CM-929P Revised Jan. 2021
Representative Payee Reporting Instructions 

All representative payees are required to account annually. This is your Representative Payee Report. You 

must complete and return the report whether you are the beneficiary’s relative, friend, or court-appointed 

guardian, or you are an official of a bank or a public or private agency or institution. You should keep a record 

of the amount of benefits you received and how you used them, because the report will be reviewed by the 

U.S. Department of Labor and is subject to verification. You will be notified if verification is required. DO NOT 

submit receipts, canceled checks, etc., with this report. If you need help completing the report, please contact 

the nearest office listed below. THIS REPORT MUST BE COMPLETED AND RETURNED WITHIN THIRTY 

DAYS OR BENEFITS MAY BE AFFECTED. 

Medical Benefit Information 

If the beneficiary is a miner, the Black Lung Disability Trust Fund is responsible for payment of his/her black 

lung-related medical expenses. However, if the beneficiary also receives benefits for a black lung condition 

from a state or another federal workers’ compensation program, the black lung-related medical expenses may 

be paid, partially or totally, by the party who pays those benefits. 

Unless another party is responsible for payment of the black lung related medical expenses, the miner should 

continue to use the Black Lung Identification Card when receiving medical treatment for his/her black lung 

condition. Examples of black lung-related medical services are: hospitalizations, doctor’s office visits, medically 

prescribed drugs, certain types of medical equipment (such as oxygen machines), home nursing services, 

pulmonary rehabilitation, and the reasonable cost for travel to and from a medical facility for the treatment of 

the black lung condition. 

If you have any questions concerning the medical coverage for the miner's black lung condition, you should 

contact your Black Lung District Office at the toll free 800 number appearing at the top left corner of page 1. 

Computer Matching Program 

The Department of Labor will match this information by computer with the Social Security Administration. Any 

information provided by applicants for and recipients of financial assistance or payments under federal benefits 

programs may be subject to verification by Department of Labor computer matches with these agencies. 

BLACK LUNG DISTRICT OFFICE TOLL-FREE NUMBERS

Greensburg, PA 

Charleston, WV 

Mt. Sterling, KY 

Denver, CO 

Washington, DC

Johnstown, PA 

Parkersburg, WV 

Pikeville, KY 

Columbus, OH

800-347-3753 

800-347-3749 

800-366-4628 

800-366-4612 

800-347-2503

800-347-3754 

800-347-3751 

800-366-4599 

800-347-3771

PRIVACY ACT NOTICE 

The following statement is made in accordance with the Privacy Act of 1974 5 U.S.C. 552a. This report is 

authorized by law (30 U.S.C. 922 and 20 CFR 725.513). Your cooperation is needed to ensure that Black 

Lung benefits are being received in the correct amount and that the beneficiary’s needs are being met. (1) 

Failure to provide all or part of the information could prevent an accurate and timely decision as to your 

continued suitability as representative payee. The information you furnish on this form may be used by other 

agencies or persons in handling matters relating, directly or indirectly, to the subject matter of the claim, 

including potentially liable coal mine operators and their insurance carriers; medical professionals in obtaining 

medical services or evaluations; contractors providing automated data processing services to the Department 

of Labor; representatives of the parties to the claim; and federal state or local agencies in obtaining 

information about eligibility for benefits. (2) Furnishing all requested information will facilitate the claims 

adjudication process; and the effects of not providing all or any part of the requested information may delay 

the process, or result in an unfavorable decision or a reduced level of benefits. (3) This information is included 

in a System of Records, DOL/OWCP-2, DOL/OWCP-9, published at 81 Federal Register 25765, 25858, 

25866 (April 29, 2016), or as updated and republished.

CM-929P Revised Jan. 2021
PUBLIC BURDEN STATEMENT 

We estimate that it will take an average of 6-80 minutes per response to complete this collection of 

information, including time for reviewing instructions, searching existing data sources, gathering and 

maintaining the data needed, and completing and reviewing the collection of information. If you have any 

comments regarding these estimates or any other aspect of this collection of information, including 

suggestions for reducing this burden, send them to the U.S. Department of Labor, Division of Coal Mine 

Workers’ Compensation, Room N-3464, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT 

SEND THE COMPLETED FORM TO THIS OFFICE. 

Note: Persons are not required to respond to this collection of information unless it displays a currently valid 

OMB control number. 

NOTICE 

If you have a substantially limiting physical or mental impairment, federal disability nondiscrimination law gives 

you the right to receive help from OWCP in the form of communication assistance, accommodation and 

modification to aid you in the claims process. For example, we will provide you with copies of documents in 

alternate formats, communication services such as sign language interpretation, or other kinds of adjustments 

or changes to account for the limitations of your disability. Please contact our office or the claims examiner to 

ask about this assistance.

CM-929P Revised Jan. 2021
OMB No.: 1240-0028 

Expires: 05/31/2024

Department of Labor

Report of Changes That May Affect 

Your Black Lung Benefits

U.S. DEPARTMENT OF LABOR 

OWCP/DCMWC

IMPORTANT NOTICE: This ANNUAL REPORT OF CHANGES must be completed, signed, 

dated, and returned within thirty (30) days of receipt. Below, you will find information about the beneficiary’s 

federal black lung benefits. If the information is not correct or if you have changes to report, enter the new 

information in the space provided below each statement or question.

1. If you and/or the beneficiary have changed address or telephone number, provide the new information below, even if 

the benefits are direct deposit.

Telephone Number:

2. List the name and telephone number of a relative or close friend we can contact, if we are unable to contact you.

Telephone Number:

3. The beneficiary's monthly black lung benefit payment is (Monthly Check Amount): 

If the beneficiary also receives BLACK LUNG benefits from another federal or state workers' compensation program, 

provide the following:

Source: Amount: Frequency of Payment:

4. Check the proper box below if the beneficiary's marital status has changed.

Death of Spouse -

Separation from Spouse -

Divorce -

Marriage -

Date of Death

Date of Separation

Date of Divorce

Date of Marriage Name of Spouse

Social Security Number of Spouse:

5. During the last twelve months, if any children who receive FEDERAL BLACK LUNG benefits along with the beneficiary 

had a change in their condition(s), please provide the following information. 

Child's Name Date of Birth Date of Marriage Date School 

Attendance Ended

Date Disability 

Began Date of Death

CM-929P Revised Jan. 2021

Telephone Number:

Claimant's Name: DOL's Case ID Number: 

Address:
Beneficiary-Representative Payee Relationship 

7. Check below all places the beneficiary lived during the last twelve months. 

Nursing Home, Personal Care Home, Assisted Living Facility, or any other location – Go to question 9 

(Skip question 8).

With you (private residence) – Go to question 8 below.

8. Note: After answering this question, go next to question 19 (skip questions 9 through 18) 

a. Has the beneficiary lived with you for the entire period? If no, please explain 

under comments below. 

Yes No

b. How are you related to the beneficiary?

c. Were all of the beneficiary’s benefits received during this period used or saved 

for the beneficiary? If no, please explain under comments below. 

Yes No

d. Were the benefits spent for the beneficiary on items other than food, shelter 

and personal needs? If yes, please explain below under comments. 

Yes No

Comments:

9. Give the name and address of each person with whom or each facility where the beneficiary lived during the 

last twelve months. 

Name and Address Date of residence:

From:

To:

Name and Address Date of residence:

To:

From:

10. How did you find out what the beneficiary’s needs were?

Letter? Yes No

11. Do you maintain contact with the beneficiary by: 

Telephone? Yes No E-mail? Yes No

Page 2 CM-929P Revised Jan. 2021

Visit? Yes No

6. FOR COAL MINERS UNDER AGE 67, AND DISABELD ADULT CHILDREN, ONLY: If the beneficiary is 

working and earning money from any type of employment, please give us the following information.

Employer:

Total earnings last calendar year:

Estimated earnings for this year:
15. How available black lung benefits were used during the reporting period: 

a. Amount used for beneficiary’s food and shelter: (Show in “Remarks” section 

of this report the name and address of the any person or entity receiving food 

and shelter payments.) 

b. Amount used for beneficiary’s clothing: 

f. Amount used for other items: (show purpose for which funds were used 

in “Comments/Additional Information” section of this report): 

c. Amount used for beneficiary’s medical and dental care: 

d. Amount used for personal needs of the beneficiary: 

e. Amount used for support of beneficiary’s dependents: 

Black Lung Benefit Accounting 

We advised when you were selected as representative payee for the beneficiary, that you are required 

to account annually for the federal black lung benefits received and spent. Please complete the 

following questions; do not submit receipts, cancelled checks, etc., with this report. 

(You will be notified later if verification is required) 

Accounting for the Period (Start Date of Accounting Period): 

 To (End Date of Accounting Period):

12. Funds on hand from black lung benefits at beginning of this report period: If you 

have filed a previous U.S. Department of Labor black lung representative payee 

accounting report, this amount should be the same as the figure shown on your last 

report (item 17) as remaining balance.

13. Total black lung benefits received during the reporting period:

14. Total black lung funds available during this reporting period: (Item 12 plus 13) 

16. Total amount used during the reporting period (Add 15a through 15f) 

17. Balance remaining at the end of this period. (Item 14 minus Item 16) If zero, go to 

Item 20.

18. How is balance of the funds, shown in Item 17, held, saved, or invested? 

Amount Name(s) that appears on each account.* 

Cash: 

Checking Account: 

Insured savings account: 

U.S. Savings Bonds: 

Other (Specify): 

* Benefits shall be held in an interest bearing account which shows that the money belongs to the beneficiary, 

i.e., “Your name for beneficiary”, “Beneficiary’s name by your name”, “Your name on-behalf-of (OBO) 

beneficiary,” etc. If you are not sure whether the account you have established shows this ownership, you 

should consult your bank and, if necessary, change the account title appropriately. 

Page 3 CM-929P Revised Jan. 2021

Payee: Type of Claim: DOL's Case ID Number:
19. If all benefits received during this reporting period were held, saved, or invested, please explain how the 

beneficiary’s needs were met: 

Source: Frequency of Payment: Amount:

20. During this period, did the beneficiary have any benefits/income other than U.S. Department of Labor 

Black Lung Benefits?

Source: Frequency of Payment: Amount:

Yes No If “Yes”, please indicate the source of the income: 

21. Have you ever been convicted of a felony? 

Yes No If yes, explain below in remarks section. 

Remarks:

22. This form must be signed and dated.

I CERTIFY THAT ALL OF THE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. If you 

conceal or fail to disclose a reporting event with an intent to obtain benefits fraudulently, either in a greater 

amount or when no payment is authorized, you may be fined, imprisoned, or both, as provided in 30 U.S.C. 

941. If you misuse benefits received as a representative payee, you may be convicted of a felony and fined 

under Title 18, U.S.C., or imprisoned for not more than 5 years, or both. The court may also order restitution. 

42 U.S.C. 408, incorporated by 30 U.S.C. 923(b), 940.

Representative Payee’s Signature/Mark Date

Witness signatures are required only if the payee’s signature above has been signed by mark (X). 

Witness’ Signature Date Witness’ Signature Date

Comments/Additional Information

Page 4 CM-929P Revised Jan. 2021
Page 5 CM-929P Revised Jan. 2021

TWO FILING OPTIONS: 

1. To file electronically, submit completed form and accompanying documentation to the 

COAL Mine Portal: 

https://eclaimant.dol.gov/portal/?program_name=BL

 

2. To file by mail, use the enclosed envelope to submit completed form and accompanying 

documentation to: 

U.S. Department of Labor OWCP/DCMWC 

PO Box 8307 

London, KY 40742-8307