U.S. Department of Labor Operator Controversion Employment Standards Administration Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation This information is authorized by the Black Lung Benefits Act (30 U.S.C. 901 at. seq.). This collection explains your reasons for not agreeing with the initial findings and is required to retain your rights to contest the findings in this black lung claim [20 CFR 725.413 (B) (3)]. Miner's Name OMB No. 1215-0058 Expires: 10-31-2007 Claim Number A. Controversion of Liability This firm is not the responsible operator because: This miner was never an employee of this firm This firm was not the operator with whom the miner had the most recent period of cumulative employment of one year. This firm was not an operator of a mine or other covered facility for any period on or after June 30, 1973. The miner was not employed by this firm during the times alleged on the claim form. His/her periods of employment with this firm were: 1. From Location of Mine 2. From to Name of Mine (State) (County) to Name of Mine Location of Mine (County) (State) Other, Explanation: B. Controversion of Eligibility of Claimant The claim was not timely filed. The miner did/does not have pneumoconiosis. The miner was/is not totally disabled by pneumoconiosis. The miner's pneumoconiosis was not caused by his coal mine employment. The miner's death was not due to pneumoconiosis. American LegalNet, Inc. www.USCourtForms.com Form CM-970 Rev. Dec. 1999 The following dependents of the claimant are not qualified: 1. Name Reason 2. Name Reason 3. Name Reason C. Controversion of Benefit Amount The computed amount of the initial payment is incorrect. Our computation indicates it is $ Explain your computation (Including augmentation for dependents): D. Controversion of Other issues (Explain) Notice: This firm intends to submit evidence in support of this controversion. (See 20 CFR 725.414 at. seq. for requirements regarding submission of evidence.) Signature Title Date Name and Address of Firm Public Burden Statement Public reporting burden for this collection of information is estimated to average 15 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, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. Note: 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