Cm-911a - United States Department Of Labor Page 2
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1
21.
3.
4.
2.
5.
Name and Address of Employer
Type of Industry
Occupation
Period of
Exposure to dust,
(City and State)
(indicate if coal mining, extraction
(Specify type
Employment
gases, or fumes?
or preparation of coal, coal mine
of work)
construction, or transportation in
or around a coal mine, steel,
Mo/Yr
Mo/Yr
(Yes/No)
manufacturing or other)
Yes
No
Yes
No
Yes
No
Yes
No
I hereby certify that the Information given by me on and In connection with this form Is true and correct to the best of my
knowledge and belief. I am also fully aware that any person who willfully makes any false or misleading statement or
representation for the purpose of obtaining any benefit or payment under this title shall be guilty of a misdemeanor and on
conviction thereof shall be punished by a fine of not more than $1,000, or by Imprisonment for not more than one year or both.
7. Date (Month, date, year)
6. Signature of Claimant (First, middle, last)
8. Mailing Address (Number, Street, Apt. No., P.O. Box or Rural Route)
9. City and State
10. ZIP Code
County where you live
12. Telephone number (include area code)
11.
Witnesses are required only if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to
the signing who know the applicant must sign below, giving their full address.
Signature of Witness
Signature of Witness
Address (Number, Street, City, State & ZIP Code)
Address (Number, Street, City, State & ZIP Code)
city:
city:
state:
zip:
state:
zip:
PRIVACY ACT STATEMENT
The following statement is made in accordance with the Privacy Act of 1974, as amended (5 U.S.C 552a).
Submission of this report
(1)
is required under the Black Lung Benefits Act. (2) The information in the report will be used to determine eligibility under the Act. (3) The
information may be used by other agencies or persons in handling matters relating, directly or indirectly, to the subject matter of the claim,
so long as such agencies or persons have received the consent of the individual claimant or beneficiary, or have complied with the provisions
of 20 CFR Part 725.
Furnishing all requested information will facilitate the claims adjudication process; and the effects of not providing
(4)
all or any part of the requested information may delay the process, or result in an unfavorable decision or a reduced level of benefits.
(Disclosure of your social security number is voluntary; the failure to disclose such number will not result in the denial of any right, benefit
or privilege to which an individual may be entitled.)
Public Burden Statement
Public reporting burden for this collection of information is estimated to average 40 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 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
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