About this form

This form is to be used to repay the Black Lung Trust Fund for benefits that were paid to the beneficiary prior to the final award being awarded.

Please note that reimbursement submissions should only be made if directed by DCMWC and the debtor has all information specific to the reimbursement. Reimbursement submissions without the valid information will be rejected.

Accepted Payment Methods:

• Bank account (ACH)
• PayPal account
• Debit card