Form CM-981 Certification By School Official

Certification by School Official
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U. S. Department of Labor
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Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

This report is authorized by law (30 U.S.C., 901 et. seq.) While completion of this form is voluntary,
cooperation is needed in returning this form to determine the claimant's eligibility under the Act.

OMB No. 1215-0061
Expires: 05-31-2007

This certification is requested on behalf of the student named below to determine his/her entitlement to black lung benefits on
the record of the worker named below. Your cooperation in promptly completing and returning this form will be appreciated. An
envelope requiring no postage is enclosed for your use. (Please see reverse side for the Privacy Act statement before completing
this form.)
Name and Address of School (include branch or campus and division)

In Replying, Address:
U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

Attn: Registrar
Telephone No.

Date

Name of Miner on whose earnings claim is based

Miner's claim Number

Student
Student's Name

Student's Date of Birth (mo., day, yr.)

Student identification Number used by School (If none, enter "None".)

Student's Social Security Number (If none, enter
"None".)

Complete All Items Below Giving Information Only For Period Indicated.
Attendance
To (mo., day, yr.)

From (mo., day, yr.)

Present

Certification By School Official
1. Is the above student now in "Full-Time Attendance" According to the School's Standards and Practices? (For evening students use the same
standards applicable to day students.)
No
Yes
2. Was the above student in "Full-Time Attendance" According to the School's Standards and Practices during entire period entered above?
Yes
No (If "No", answer 3.)
3. If item 2 is answered "No" Please enter the beginning and ending dates (up to the present) of the
student's Full-Time Attendance. If none, enter "None". (If more space is needed, use space on the
reverse.)
4. Check the type
of School:

Junior College, College or University

High School

Technical, Trade or Vocational

Other (Specify)

From: (Mo., day, yr.)
To: (Mo., day, yr.)

5. (To be completed by all schools except junior colleges, colleges, or universities.) Enter the total clock hours
per week the student is (was) scheduled to attend. Show any variations in scheduled attendance on the
reverse.

Total hours per week

Knowing that anyone making a false statement or representation of a material fact for use in determining a right to payment
under the Black Lung Benefits Act, commits a crime punishable under Federal Law, I certify that according to this institution's
records the information given above is true.
School Official
Signature of School Official

Title

Date

Form CM-981
Rev. June 1998

Privacy Act Statement
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 410 or 20 CFR 725. (4) Furnishing all requested information will facilitate
the claims 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. (Disclosure of your social security number is voluntary; the failure to disclose such
number will not result in the denial of any right, benefit or privilege to which an individual may
be entitled.)

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 Mine Workers' Compensation, Room N3464, 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.