U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation Operator ResponseOMB No. 1215-0058 Expires: 09-30-04Claim Number Claim Type Operator's NameCOURT COUNTY OFThis report is authorized by the Black Lung Benefits Act. (30 U.S.C. 901 et seq.) While you are not required to respond, failure to do so may be deemed as acceptance of potential liability (20 CFR 725.413 (a)). Acceptance of Liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.This firm is the responsible operator within the meaning of the Black Lung Benefits Act.JUDICIAL SUBPOENAControversion of LiabilityPlaintiff(s) -against-Defendant(s)This firm is not the responsible operator because:The miner was never an employee of this firm.This firm was not the operator with whom the miner had the most recent period of cumulative employment of one year.This firm was not an operator of a mine or other covered facility for any period after June 30, 1973.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The miner was not employed by this firm during the times alleged on the claim form. His/her periods of employment with this firm were:THE PEOPLE OF THE STATE OF NEW YORK TOName of Mine To 1. From(County) Location of Mine(State)GREETINGS:To 2. FromName of MineWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable(County) Location of Mine(State),Other (Explain):located at County 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 roomo'clock in the day ofYour 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 theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Name & Address of FirmSignatureDateAttorney(s) forTitleOffice and P.O. AddressPublic Burden StatementPublic 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 Miner Workers' Compensation, Room C3526, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICETelephone No.: Facsimile No.: E-Mail Address:Form CM-970a Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.Mobile Tel. No.:Rev. Jan. 01American LegalNet, Inc. www.USCourtForms.com
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