U.S. Department of Labor Employment Standards Administration Division of Coal Mine Workers' Compensation Affidavit of Deceased Miner's ConditionThis report is authorized by law (30 USC 901 et. seq.) While you are not required to respond, your cooperation is necessary to ensure that full and proper consideration is given to this claim.OMB No. 1215-0056 Expires: 04-30-05Miner's NameDOL Claim NumberRelationship to MinerYour Name2. Were you living with the miner at the time of the miner's death? 1. Did you live with the miner?If ''Yes,'' how long? No YesYesNoyears3. How long did you know the miner?4. How often did you see the miner?time per week/mo./yr Under what circumstances? (Social occasions, working together) YearsCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.5. a. Do you believe that the miner suffered from any disease of the lung?YesNoCalendar No.If ''Yes,'' what disease(s) do you think the miner suffered?JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)b. What led you to believe the miner suffered from this disease? (Describe the condition and symptoms). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:6. How long did the miner have the symptoms described above?WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County of, on the, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20noon, and at any recessed in roomo'clock in the day of7. Did the miner's condition limit the ability to walk or perform other activities?YesNoBased on your personal observation, describe the activities the miner was unable to perform.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of the, 20 County,day ofCourt in Witness, Honorable(Attorney must sign above and type name below)Attorney(s) for8. Based on your personal knowledge, how long did the miner have the limitations described above?Public Burden StatementOffice and P.O. AddressWe estimate that it will take an average of 30 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 C3526, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.Telephone No.: Facsimile No.: E-Mail Address:Form CM-1093 Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.Mobile Tel. No.:Rev.Feb.1999American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.To be completed only If you worked with the miner In or around the coal mines.9. Was the miner unable to perform his/her assigned job duties?YesNo If 'Yes," state which duties:Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)10. How long was the miner unable to perform the job duties listed above? 11. To your knowledge, was the miner given different or lighter duties because the miner was unable to perform the usual job duties?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No If so, describe the changed circumstances of work. YesTHE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:Privvacy 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 of 1977. (2) The information will be used to determine eligibility for and ft amount of benefits payable under the Act. (3) The informa-tion 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 Part 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.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomI 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 gives 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.Date (Mo., day, yr.)Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Telephone Number Signature (First name, middle initial, last name), one of the Justices of theMailing Address (Number, Street, Apt. No. P.O. Box or Rural Route)Court in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)City and StateZIP CodeCounty in which you now live (If any)Attorney(s) forWitnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X) two witnesses to the s
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