Coal Mine Employment Affidavit U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation OMB No. 1215-0056 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 full and proper consideration is given to the referenced claim. Expires: 04-30-2008 2. Miner's Claim No. 1. Miner's Full Name (First, Middle, Last) 3. Your Name (First, Middle, Last) 4. Age 5. Are You Related to the Above Miner? Yes No if "Yes," give your relationship. 6. Did you work in the coal mining industry? No Yes If "Yes, '' give the name and address of your employers, type of work, and dates of employment below: d. C. b. a. Your Job Location Name of Company 7. Give your knowledge of the minor's employment: a. b. Name of Company Location C. His/Her Job Dates (mm/dd/yyyy) (From) d. (From) (mm/dd/yyyy) (To) (To) (mm/dd/yyyy) American LegalNet, Inc. www.USCourtForms.com Form CM-918 Rev. Feb 1999 8. Explain how you know the information relating to the miner's employment 9. Give names and address of other people who also have knowledge of the miner's coal mine work: a. Name Address (Number, Street, City, State, ZIP Code) b. Name Address (Number, Street, City, State, ZIP Code) I know that anyone who makes a false statement or representation of a material fact in an application or for use in determining a right to payment under the Federal Mine Safety and Health Act of 1977, as amended, commits a crime punishable under Federal Law. I affirm that the above statements are true. Signature of person making statement (Write in ink) Date (Month, Day, Year) Address (Number, Street, City, State, ZIP Code) Telephone Number (include area code) Public Burden Statement We estimate that it will take an average of 10 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding these estimates or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S. Department of Labor, Division of Coal Mine Workers' Compensation, Room C3526, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. American LegalNet, Inc. www.USCourtForms.com