COURT COUNTY OFU.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation Coal Mine Employment Affidavit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.OMB No. 1215-0056 Expires: 04-30-05 This report is authorized by the Black Lung Benefits Act (30 U.S.C. 901 et seq.). While you are not required to respond, your cooperation is needed to ensure that full and proper consideration is given to the referenced claim.Calendar No.2. Miner's Claim No. 1. Miner's Full Name (First, Middle, Last)JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)5. Are You Related to the Above Miner? 4. Age 3. Your Name (First, Middle, Last)No Yesif "Yes," give your relationship.6. Did you work in the coal mining industry?No Yes '' give the name and address of your employers, type of work, and dates of employment below: If "Yes,d. b. a.C.Dates (mm/dd/yyyy) Your Job Location Name of Company. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(From)(To)THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS: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 ofnoon, and at any recessed in room, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of theYour 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.7. Give your knowledge of the minor's employment:a.b.C.Name of CompanyLocationHis/Her Jobd. (From) (mm/dd/yyyy)(To) (mm/dd/yyyy), one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:Form CM-9 Rev. Feb 1999American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::8. Explain how you know the information relating to the miner's employmentIndex No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS: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 roomYour 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.9. Give names and address of other people who also have knowledge of the miner's coal mine work: a. Nameb. Name, one of the Justices of theCourt in Witness, Honorableday of, 20 County,Address (Number, Street, City, State, ZIP Code)Address (Number, Street, City, State, ZIP Code)(Attorney must sign above and type name below)I know that anyone who makes a false statement or representation of a material fact in an application or for use in determining a right to payment under the Federal Mine Safety and Health Act of 1977, as amended, commits a crime punishable under Federal Law. I affirm that the above statements are true.Attorney(s) forDate (Month, Day, Year) Signature of person making statement (Write in ink)Telephone Number (include area code) Address (Number, Street, City, State, ZIP Code)Office and P.O. AddressPublic Burden StatementTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:We estimate that it will take an average of 10 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 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, 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. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.American LegalNet, Inc. www.USCourtForms.com
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