Operator Response Form. This is a Official Federal Forms form and can be use in US Dept Of Labor.
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U.S. Department of Labor Operator Response Employment Standards Administration Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation Operator's Name Claim Type Claim Number OMB No. 1215-0058 Expires:10-31-2007 This report is authorized by the Black Lung Benefits Act. (30 U.S.C. 901 et seq.) While you are not required to respond, failure to do so may be deemed as acceptance of potential liability (20 CFR 725.413 (a)). Acceptance of Liability This firm is the responsible operator within the meaning of the Black Lung Benefits Act. Controversion of Liability This firm is not the responsible operator because: The 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 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 To (County) Location of Mine 2. From Location of Mine Name of Mine (State) To Name of Mine (County) (State) Other (Explain): Name & Address of Firm Signature Date Title Public Burden Statement Public reporting burden for this collection of information is estimated to average 10 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 Miner 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. Form CM-970a Rev. Jan. 01 American LegalNet, Inc. www.USCourtForms.com