Form CM-981 Certification by School Official

Certification by School Official	U.S. Department of Labor Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation
This report is authorized by the Black Lung Benefits Act (30 U.S.C. 901 et. seq.). While completion of this form is voluntary, we need your cooperation so that we may determine eligibility or payments due on a claim for benefits under the Act. We would appreciate your prompt completion and return of this form. An envelope requiring no postage is enclosed for your use. (Please see the Privacy Act statement before completing this form.)		OMB No. 1240-0031 Expires: XX/XX/XXXX

Name and Address of School: (include branch or campus and division) Attn: Registrar	TWO FILING OPTIONS: To file electronically, submit completed form to the COAL Mine Portal: https://eclaimant.dol-esa.gov/bl To file by mail, send completed form to: US Department of Labor OWCP/DCMWC PO Box 33610 San Antonio, TX 78265
	Telephone Number:	Date:
Name of Miner on whose earnings claim is based:	DOL’s Case ID Number:

Student

Student's Name: (Last, First, Middle)	Student's Date of Birth (mo, day, yr.)
Student Identification Number used by School (If none, enter "None.")
Student's Expected Graduation Date

Complete All Items below Giving Information Only for Period Indicated.

Attendance

From (mo., day, yr.) To (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 Practice's? (For evening students use the same

standards applicable to day students). Yes  No

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.)	From (mo., day, yr.)
	To (mo., day, yr.)

4. Check the type of school:  Junior College, College or University  High School

 Technical, Trade or Vocational  Other (Specify) _______________________________

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 a person who willfully makes any false or misleading statement or representation to obtain benefits or payments under the Black Lung Benefits Act shall be guilty of a misdemeanor under 30 USC 941 and, on conviction, subject to a civil money penalty or imprisonment for up to one year, or both, I certify that according to this institution's records the information given above is true.

School Official

Phone Number:	E-Mail Address	Date
Signature of School Official	Title

Form CM-981

Rev. May 2019

Privacy Act Statement

The following information is provided in accordance with the Privacy Act of 1974, 5 U.S.C.552a. (1) Collection of this information is authorized by the Black Lung Benefits Act (30 U.S.C. 902(g)) and implementing regulations (20 CFR 725.209, 725.218-219). (2) The information will be used to determine eligibility for and the amount of benefits payable under the Act. (3) This information may be used by other agencies or persons handling matters relating, directly or indirectly, to processing this form including liable coal mine operators and their insurance carriers; contractors providing automated data processing or other services to the Department of Labor; representatives of the parties to the claim; and federal, state or local agencies. This would include legal representatives; state workers’ compensation agencies or the Social Security Administration, for the purpose of determining benefit payment offsets; the Internal Revenue Service and other federal, state, and local agencies for the purpose of conducting investigations relating to the payment of benefits; and debt collection agencies and credit bureaus for the purpose of collecting overpayments that might be made to the beneficiary. (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. (5) This information is included in a System of Records, DOL/OWCP-2, published at 81 Federal Register 25765, 25858 (April 29, 2016), or as updated and republished.

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.

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 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.

OMB No. 1240-0031

Expires: XX/XX/XXXX