[Code of Federal Regulations]
[Title 20, Volume 2]
[Revised as of April 1, 2004]
From the U.S. Government Printing Office via GPO Access
[CITE: 20CFR422.512]

[Page 1092-1093]
 
                      TITLE 20--EMPLOYEES' BENEFITS
 
               CHAPTER III--SOCIAL SECURITY ADMINISTRATION
 
PART 422_ORGANIZATION AND PROCEDURES--Table of Contents
 
                Subpart F_Applications and Related Forms
 
Sec. 422.512  Applications and related forms used in the black lung benefits 
program.

    (a) Application forms. The following forms are prescribed for use in 
applying for entitlement to benefits under part B of title IV of the 
Federal Coal Mine Health and Safety Act of 1969, as amended by the Black 
Lung Benefits Act of 1972:

SSA-46--Application for Benefits Under the Federal Coal Mine Health and 
Safety Act of 1969, as Amended (Coal Miner's Claim of Total Disability).
SSA-47--Application for Benefits Under the Federal Coal Mine Health and 
Safety Act of 1969, as Amended (Widow's Claim).
SSA-48--Application for Benefits Under the Federal Coal Mine Health and 
Safety Act of 1969, as Amended (Child's Claim).

[[Page 1093]]

SSA-49--Application for Benefits Under the Federal Coal Mine Health and 
Safety Act of 1969, as Amended (Parent's, Brother's and Sister's Claim).

    (b) Related forms. The following are some related forms:

SSA-50--Request To Be Selected as Payee. (For use when the individual 
proposing to be substituted for current payee files application to 
receive payment of black lung benefits on behalf of himself, a disabled 
child or child under age 18, a student beneficiary, or an incompetent 
beneficiary.)
SSA-2179--Report by Person Entitled to Black Lung Benefits. (For use by 
person entitled to black lung benefits to report events which affect 
benefits.)
SAA-2210--Statement of Coal Mine Employment by United Mine Workers of 
America.
SSA-2325--Medical Report (Pneumoconiosis).

[38 FR 11451, May 8, 1973]