Official Federal Forms > US Dept Of Labor
Operator Response To Schedule For Submission Of Additional Evidence CM-2970 - Official Federal Forms
| Operator Response To Schedule For Submission Of Additional Evidence Form. This is a national form and can be used in US Dept Of Labor . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
23(5$725 5(63216( 72 6&+('8/( )25 68%0,66,21 2) $'',7,21$/ (9,'(1&( 0LQHU V 1DPH 5HVSRQVLEOH 2SHUDWRU V 1DPH U.S. Department of Labor 2IILFH RI :RUNHUV &RPSHQVDWLRQ 3URJUDPV 'LYLVLRQ RI &RDO 0LQH :RUNHUV &RPSHQVDWLRQ &ODLP 1XPEHU 20% 1R ([SLUHV 3ROLF\ 1R &ODLPDQW V 1DPH ,QVXUHU V 1DPH 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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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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ñ 6LJQDWXUH Public Burden Statement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merican LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
