U.S. DEPARTMENT OF LABOR 

Office of Workers' Compensation 

Division of Coal Mine Workers’ Compensation

PLEASE KEEP THIS FOR YOUR RECORDS AND FOR FUTURE REFERENCE. 

 

Instructions For CM-929 

These events could affect the amount of your monthly check. If not reported timely and you are 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. 

Medical Benefit Information

If you are a miner, the Black Lung Disability Trust Fund is responsible for payment of your black lung-related 

medical expenses. However, if you also receive 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, you should 

continue to use the Black Lung Identification Card when receiving medical treatment for your 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. 

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 3. The form contains information the 

Department of Labor has concerning your 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:

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 

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)

CM-929 Revised (Jan. 2021)
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. 

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 725.533(e)). Your cooperation is needed to ensure that Black 

Lung benefits are being received in the correct amount. (1) Failure to provide all or part of the information 

could prevent an accurate and timely decision as to the beneficiary’s continued entitlement. 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 Systems of Records, DOL/OWCP-2, DOL/OWCP-9, published at 

81 Federal Register 25765, 25858, 25866 (April 29, 2016), or as updated and republished. 

 

PUBLIC BURDEN STATEMENT 

We estimate that it will take an average of 5-8 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.

800-347-3754 

800-347-3751 

800-366-4599 

800-347-3771

Johnstown, PA 

Parkersburg, WV 

Pikeville, KY 

Columbus, OH

800-347-3753 

800-347-3749 

800-366-4628 

800-366-4612 

800-347-2503

Greensburg, PA 

Charleston, WV 

Mt. Sterling, KY 

Denver, CO 

Washington, DC

BLACK LUNG DISTRICT OFFICE TOLL-FREE NUMBERS

CM-929 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 

200 Constitution Ave. NW 

Washington, DC 20210

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 your 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 have changed your address or telephone number, provide the new information below, even if your benefits are 

direct deposit.

Telephone Number:

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

 unable to contact you.

Name: Telephone Number:

Address:

3. Your monthly black lung benefit payment is (Monthly Check Amount): 

If you also receive 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 your 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:

Page 1 CM-929 Revised (Jan. 2021)

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

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

Your Name: Telephone Number:

DOL's Case ID Number: 
COMMENTS/ADDITIONAL INFORMATION:

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. 

Beneficiary's Signature or "Mark" Date

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

Witness’ Signature Date Witness’ Signature Date

Reason beneficiary did not sign or make mark: 

Page 2 CM-929 Revised (Jan. 2021)

THIS FORM MUST BE SIGNED AND DATED.

Employer:

Total earnings last calendar year:

Estimated earnings for this year:

6. FOR COAL MINERS UNDER AGE 67, AND DISABLED ADULT CHILDREN, ONLY: If you are working and 

earning money from any type of employment, please give us the following information.
Page 3 CM-929 Revised (Jan. 2021)

TWO FILING OPTIONS: 

 

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

Portal: 

 

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 

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