PRIVACY ACT NOTICE
In accordance with the Privacy Act of 1974 (5 U.S.C. 552a), as amended, you are hereby notified that: (1) the Black Lung Benefits Act (BLBA)
(30 U.S.C.901 et seq.), as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of
Labor, which receives and maintains personal information, relative to this application, on claimants and their immediate families;
(2) information obtained by OWCP will be used to determine eligibility for benefits payable under the BLBA; (3) information may be
given to coal mine.operators potentially liable for payment of the claim or to the insurance carrier or other entity which secured the operator's
compensation liability; (4) information may be given to physicians or other medical service providers for use in providing treatment, making
evaluations and for other purposes relating to the medical management of the claim; (5) information may be given to the Department of
Labor's Office of Administrative Law Judges, or other person, board or organization, which is authorized or required to render decisions with
respect to the claim or other matters arising in connection with the claim; (6) information may be given to Federal, state or local agencies for
law enforcement purposes, to obtain information relevant to a decision under the BLBA, to determine whether benefits are being or have been
paid properly, and where appropriate, to pursue administrative offset and/or debt collection actions required or permitted by law;
(7) disclosure of the claimant's or deceased miner's Social Security Number (SSN) or tax identifying number (TIN) on this form is voluntary,
law; (8) failure to disclose all requested information, other than the SSN or TIN, may delay the processing of this claim or the payment of
and the SSN and/or TIN and other information maintained by the OWCP may be used for identification and for other purposes authorized by
benefits or may result in an unfavorable decision or reduced level of benefits.
COMPUTER MATCHING PROGRAM. The Department of Labor conducts computer matches with the Social Security
Administration. Any information provided by applicants for and recipients of financial assistance or payments under
Federal benefit programs may be subject to verification through computer matches which the Department of Labor
conducts with the Social Security Administration.
SIGNATURE OF APPLICANT
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.
Signature in ink (First, Middle, Last)
Date
Mailing Address (Number, Street, Apt. No., PO Box, Rural Route)
County you live in
City, State, ZIP Code
Area Code and Telephone Number
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 WitnessSignature of Witness
Address of Witness
Address of Witness
City, State, ZIP Code
City, State, ZIP Code
Public reporting for this collection of information is estimated to average 8 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 U. S. Department of Labor, Division of Coal
Mine Workers' Compensation, 200 Constitution Avenue, Room N-3464, Washington, DC 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.
Notice
If you have a disability, federal law gives you the right to receive help from the OWCP in the form of communication assistance,
accommodation(s) and/or modification(s) to aid you
in the OWCP claims process. For example, we will provide you with copies
of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments
of changes to accommodate your disability. Please contact our office or your OWCP claims examiner to ask about this assistance.
Page 2 Form CM-912
Rev. Oct 2015
