Description of Coal Mine Work and Other Employment U. S. Department of Labor 2IILFH RI :RUNHUV &RPSHQVDWLRQ 3URJUDPV 'LYLVLRQ RI &RDO 0LQH :RUNHUV &RPSHQVDWLRQ OMB No.  Expires:  This report is authorized by the Black Lung Benefits Act (30 U.S.C. 901 et. seq.). While you are not required to respond, your cooperation is needed to ensure that this claim is given full and proper consideration. Miner's Name Claim Number Please provide the following information concerning your current or last coal mine work, or the miner's last coal mine work prior to death. PART I - DESCRIPTION OF COAL MINE WORK 2. Dates worked (mm/dd/yyyy): 1. Job title From: 3. Highest or current rate of pay To: 4. Number of days worked per week 5. Describe the duties of this job in your own words: 6. List all other jobs you or the deceased miner did in the coal mines for at least one year. a. Job Title b. Dates Worked (Month and Year) From To Public Burden Statement Public reporting burden for this collection of information is estimated to average 30 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 C3526, 200 Constitution Avenue NW., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. Form CM-913 NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Rev. Feb. 1999 American LegalNet, Inc. www.FormsWorkFlow.com 7. Describe the physical activity required by the coal mine job described in number 5. Sitting for hours (Give number of hours per day). Standing for hours (Give number of hours per day). Crawling (distance) for hours per day. Lifting pounds times per day. pounds times per day. pounds times per day. ( Example: 25 pounds ten times per day ) Carrying pounds ( distance ) times per day. pounds ( distance ) times per day. pounds ( distance ) times per day. ( Example: 20 pounds 50 feet 15 times per day ) 8. Did the coal mine job discussed above involve: 1. The use of tools, machines or equipment:? Yes No 2. Technical knowledge or special skills? Yes No 3. Any supervisory responsibilities? Yes No Please explain all "Yes'' answers. For example, the specific type of tools, machines or equipment used; the nature of any technical knowledge or special skills needed and the nature of any supervisory duties including the number and type of employees supervised, and the extent to which they had to be supervised, etc.. 9. Were you (or the deceased miner) transferred from a previous job due to health reasons? If ''Yes'', provide the following information: a. Previous Job: c. Effective date of transfer: b. Job transferred to: d. Reason: e. If coal mine work has stopped, give reason and last date worked: American LegalNet, Inc. www.FormsWorkFlow.com PART II - DESCRIPTION OF OTHER EMPLOYMENT Please provide the following information about current or last non-coal mine employment. 11. Type of business or industry 10. Job title 12. Dates worked (mm/dd/yyyy) 13. Highest or current rate of pay 14. Number of days worked per week. From: To: 15. Describe the duties of this job in your own words: 16. Describe the physical activity required by the job described above. Sitting for hours per day. Standing for Lifting pounds times per day. pounds times per day. pounds hours per day. times per day. ( Example: 25 pounds ten times per day ) Carrying pounds ( distance ) times per day. pounds ( distance ) times per day. pounds ( distance ) times per day. ( Example: 20 pounds 50 feet 15 times per day ) 17. Did the job discussed above (10 to 16) involve: 17 a. The use of tools, machines or equipment? Yes No 17 b. Technical knowledge or special skills? Yes No 17 c. Any supervisory responsibilities? Yes No Please explain all ''Yes'' answers. For example, the specific type of tools, machines or equipment used; the nature of any technical knowledge or special skills needed and the nature of any supervisory duties including the number and type of employees supervised, the extent to which they had to be supervised, etc. 18. If work has stopped, give date of last employment and reason. Reason for stopping Date American LegalNet, Inc. www.FormsWorkFlow.com PART - III 19. Use this section for additional space to answer any previous question, or to provide any other information you feel would be helpful. Please refer to previous questions by the corresponding number. If more space is needed, use a blank sheet and attach. PRIVACY ACT The following information is provided in accordance with the Privacy Act of 1974. (1) Submission of this Information is required under the Black Lung Benefits Act. (2) The information will be used to determine eligibility for and the amount of benefits payable 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. (4) Furnishing all requested information will facilitate the claim 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. I 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. Signature of claimant or person filing on his/her behalf Date American LegalNet, Inc. www.FormsWorkFlow.com