Notice of Termination,
Suspension, Reduction, or
Increase In Benefit Payments
U.S. Department of Labor
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation
This report is required by the Black Lung Benefits Act (30 U.S.C. 901 et seq.) and is mandatory. It is to be completed in full
and filed with the Office of Workers’ Compensation Programs within 16 days following the termination of benefits, and
immediately following the suspension, reduction or increase of benefits being paid under the Black Lung Benefits Act to insure
that correct benefits are paid. Failure to report can result in a civil penalty as set forth in 20 CFR 725.621 for each such failure
or refusal.
OMB No. 1240-0030
Expires: 01-31-2022
Name and Address of Payee (Please Print) Include ZIP Code
Address Line 1
Address Line 2
State ZIP
Payee E-mail Address
Distribution copies to: Payee,
Operator and Department of Labor
Two Filing Options:
1.To file electronically, submit
completed form to the COAL Mine
bl2.To file by mail, submit completed
form to:
U.S. Department of Labor
PO Box 33610
San Antonio, TX 78265
1. Name of disabled or deceased miner
2. DOL’s CASE ID Number
3. Name of coal miner operator 4. Name of insurance carrier
5. Action taken:
Terminated Suspended
Reduced Increased
6. Reasons why action taken:
a. Date of Last Payment
b. Amount of Last Payment c. Amount of Reduced/
Increased Payment
d. Date Benefits Will
Resume (mm/dd/yyyy)
e. Date of This Notice
7. Summary of Payments
a. Name of Payee b. From c. To d. Date Benefits
Will Resume
e. Amount Paid
Per Month
f. Total
Address Line 1
Address Line 2
City ZIPState
8. Signature and address of person issuing this notice
11. E-mail Address
9. Title
10. Telephone number
Public Burden Statement
Public reporting burden for this collection of information is estimated to be 12 minutes per response, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of
Workers' Compensation Programs, U.S. Department of Labor, Room C-3520, 200 Constitution Avenue, NW, Washington, DC 20210. DO NOT SEND
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from
DCMWC 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 your claims examiner to ask about this assistance.
Note: According to the Paperwork Reduction Act of 1995, persons are not required to respond to this collection of information unless it displays a
currently valid OMB control number.
U.S. GPO:2001-479-595/89873 Form CM-908 (Rev. 01-2019)
Privacy Act Notice
The following information is provided in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. (1) Collection of this information is authorized by the Black Lung
Benefits Act (30 U.S.C. 901 et. seq.) and implementing regulations (20 CFR 725.621). (2) The purpose of the collection of information is to provide notification to
the Department of Labor of a change in the beneficiary’s benefit amount and the reason for the change. Completion of this form is mandatory. Failure to report
can result in a civil penalty as set forth in 20 CFR 725.621 for each such failure or refusal. (3) This information may be used by other agencies or persons
handling matters relating, directly or indirectly, to processing this form including liable coal mine operators and their insurance carriers; contractors providing
automated data processing or other services to the Department of Labor; representatives of the parties to the claim; and federal, state or local agencies. This
would include legal representatives; state workers’ compensation agencies or the Social Security Administration, for the purpose of determining benefit payment
offsets as specified under the Black Lung Benefits Act; the Internal Revenue Service and other federal, state, and local agencies for the purpose of conducting
investigations relating to the payment of benefits; and debt collection agencies and credit bureaus for the purpose of collecting overpayments that might be made
to the beneficiary. (4) Furnishing all requested information will facilitate accurate and timely determination of the beneficiary’s benefit amount. (5) This information
is included in a System of Records, DOL/OWCP-2, published at 81 Federal Register 25765, 25858 (April 29, 2016), or as updated and republished.
U.S. GPO:2001-479-595/89873 Form CM-908 PAGE 2 (Rev. 01-2019