Form CM-972 Application for Approval of a Representative's Fee in a

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Application for Approval of a Representative's
Fee In a Black Lung Claim Proceeding
Conducted by The U.S. Department of Labor

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U.S. Department of Labor

Office of Worker's Compensation Programs
Division of Coal Mine Workers' Compensation

NOTE: No fee for services performed may be paid under this program unless the Information prescribed by OMB No. 1240-0011
existing regulations is provided to this office. Disclosure of your Social Security Number Is voluntary; the failure Expires: 12-31-2010
to disclose such number will not result in the denial of any right, benefit or privilege to which an Individual may
be entitled.
1. In accordance with the provisions of the Black Lung Benefits Act (30 U.S.C. 901 at seq.), 33 U.S.C. 928 and the regulations of the U.S. Department
of Labor governing the administration of such Act (20 CFR 725.365 et seq.), I the undersigned hereby make application for a representative's fee for
in the claim of:
19
my services rendered from
19
to
before the: (Check only one block)
(Client's Name)
Benefits
Review
Board
Administrative
Law
Judge
District Director
(Other) (Specify)
3. Miner's Claim Number

2. Miner's Name
4. Services Rendered (Use blank sheet of paper if additional space is needed)
(a) Date Rendered

(b) Itemized services rendered
(See reverse side for instructions)

(d) Usual Billing Rate Per
Hour at Time
of Service

(c) Professional Status of
Person Who Performed
the Service

(e) Time to
Nearest
1/4 Hour

Total Time Expended on Case During Period:
5. Miscellaneous Expenses (Use blank sheet of paper if additional space is needed)
(c) Cost
(a) Date Rendered
(b) Itemize unreimbursed expenses incurred in connection with claim (See Reverse)
$

Total Miscellaneous Expenses Incurred:
6. Total Fee Requested (Amount of fee requested for services rendered and expenses incurred during the period designated in block 1
and itemized in blocks 4 and 5):
$
7. Explain on a separate sheet the nature
and extent of any unusual circumstances
or any other relevant data which should
be considered in approving your fee.
(Note: As stated in 20 CFR 725.365, no
lay representative is entitled to a lien
against the award.

8. Did you or your firm receive or request
any fee for services rendered to the claimant
in any claim for pneumoconiosis (black lung)
benefits before any state or federal agency?
Yes

No

If YES, show amount: $

9. Did you request monies from this claimant
to place in an escrow account or to use as
expense advances?
Yes

No

If YES, show amount: $
and itemize on separate sheet. (See Reverse)

Certification: I certify that the fees and expenses listed in blocks 4 through 9 constitute the complete claim for representing this client during the
period and before the adjudication official indicated in block 1. Any claim for fees or expenses for services rendered during a period or before
an official other than the period and official indicated in block 1 will be submitted on a separate CM-972. I have made no agreement and will
make no other claim (unless disclosed in block 8) which would entitle me to any portion of the proceeds the client may be awarded under the
terms of any Act administered by the Office of Workers' Compensation Programs. I certify that I have furnished a copy of this application and
any attachments to the person for whom the above services were performed and to all other parties in the claim. I certify that the information
given by me on this application is true and correct to the best of my knowledge. I am aware that severe penalties, including fine and
imprisonment, may be invoked under 33 U.S.C. 928(e) whenever any person receives an unauthorized fee for services rendered, or under
30 U.S.C. 941 whenever any person willfully makes a false or misleading statement or representation for the purpose of obtaining payment
under 30 U.S.C. 901 et seq.
10. Signature of Representative

13. Name and Address of Representative (Print or type)

11. Date

12. Telephone No. (Include Area Code)
14. Representative's Social Security Number or IRS Identification Number

Form CM-972
Rev. Sept. 1999

Instructions for Completing CM-972
Block 4 - Services Rendered
Column (b) - Itemize the services rendered on behalf of the claimant, such as:
attend conference, draft letter, prepare interrogatories, etc.
Column (c) - Enter the professional status of the person who performed the
services on behalf of the claimant, such as: attorney, paralegal, law clerk,
lay clerk, lay representative, clerical, or other status (specify).
Column (d) - Enter the customary billing rate per hour at the time of service
for each person who performed services on behalf of the claimant.
Block 5 - Miscellaneous Expenses
Column (b) - Itemize reasonable unreimbursed expenses incurred by the
representative or by an employee of the representative in establishing the
claimant's case, e.g. travel expenses, long distance phone calls, etc. Attach
all available receipts or other documentation of expenses. Please add client's
name, miner's name (if different), miner's Claim Number and representative's
name to any attachments.
Note: List the type and amount of any expenses for which you were
reimbursed in this case:
Type of Expense

Amount

Block 9 - Escrow Account/Expense Advances
Indicate amount placed in an escrow account, and/or itemize amount paid by
claimant to the representative for any expenses.
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 at 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 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 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, and the SSN and/or TIN and other information maintained by the OWCP may be
used for identification and for other purposes authorized by 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 benefits, or may result in an unfavorable decision or reduced level of benefits.
Public Burden Statement
We estimate that it will take an average of 42 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 collection of 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,
Room N-3464, 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.