Form CM-2970 Operator Response to Schedule for Submission of Addition

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OPERATOR RESPONSE TO
SCHEDULE FOR SUBMISSION OF
ADDITIONAL EVIDENCE

U.S. Department of Labor

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

Claimant's Name

Miner's Name
Responsible Operator's Name

Claim Number

OMB No. 1240-0033
Expires: 12-31-2010
Policy No.

Insurer's Name

This report is authorized by the Black Lung Benefits Act as amended (30 U.S.C. 901 et seq.) (20 CFR 725.410). Please check
appropriate boxes below. While you are not required to respond, if you fail to do so within 30 days after the District Director's
issuance of the schedule for the submission of additional evidence naming you as a responsible operator, you shall be deemed
to have accepted liability for this claim (that is, that you will be responsible for payment of benefits to which the Claimant is finally
determined to be entitled) and to have waived your right to contest your liability in any further proceeding conducted with respect
to this claim. You also will be deemed to have contested the Claimant's entitlement to benefits.
A. Liability
The named responsible operator:
Agrees it is the responsible operator within the meaning of the Black Lung Benefits Act, liable
for any benefits to which the claimant is finally determined to be entitled.

Disagrees with its designation as the responsible operator liable for this claim.

If you disagree, the schedule for the submission of additional evidence advises you of the time period within which you may submit evidence
relevant to your liability, subject to the limitations imposed by 20 C.F.R. 725.408(b)(2). Absent extraordinary circumstances, no documentary
evidence pertaining to liability shall be admitted in any further proceeding conducted with respect to this claim unless it is
submitted to the district director in compliance with a schedule for the submission of additional evidence.
B. Claimant's Entitlement
The named responsible operator:
Accepts the Claimant's entitlement to benefits.

Contests the Claimant's entitlement to benefits.

If you do not accept the Claimant's entitlement to benefits, the schedule for the submission of additional evidence will advise you of the
time period within which you may submit evidence relevant to the Claimant's entitlement. If you enter no response in this section, you
will be deemed to have contested the Claimant's entitlement to benefits.
Name and Address of Firm Completing Form

Name of Person Completing Form

Title

ñ

Signature

Date

Public Burden Statement
We estimate that it will take an average of 20 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 the burden estimate or any other aspect to this collection of information, including suggestions for
reducing this burden, send them to the U.S. Department of Labor, Division of Coal Mine Workers' Compensation, Room N-3464,
200 Constitution Avenue, N.W., Washington, D.C. 20210. NOTE: Persons are not required to respond to this collection of information unless
it displays a currently valid OMB control number. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
CM-2970
Jan. 2001