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Certification By School Official CM-981 - Official Federal Forms
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Certification by School Official U. S. Department of Labor Employment Standards Administration Office of Workers Compensation Programs Division of Coal Mine Workers Compensation This report is authorized by law (30 U.S.C., 901 et. seq.) While compl etion of this form is voluntary, OMB No. 1215-0061cooperation is needed in returning this form to determine the claimants eligibility under the Act. Expires: 05-31-2007This certification is requested on behalf of the student named below to determine his/her entitlement to black lung benefits onthe record of the worker named below. Your cooperation in promptly compl eting and returning this form will be appreciated. An envelope requiring no postage is enclosed for your use. (Please see rev erse side for the Privacy Act statement before completingthis form.) Name and Address of School (include branch or campus and division) In Replying, Address: U.S. Department of Labor Employment Standards Administration Office of Workers Compensation Programs Division of Coal Mine Workers Compensation Attn: Registrar Telephone No. DateName of Miner on whose earnings claim is based Miners claim Number Student Students Name Students Date of Birth (mo., day, yr.) Student identification Number used by School (If none, enter "None".) Students Social Security Number (If none, enter "None".) 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 Schoo ls Standards and Practices? (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 Scho ols 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 theFrom: (Mo., day, yr.) students Full-Time Attendance. If none, enter "None". (If more space i s needed, use space on the reverse.) To: (Mo., day, yr.) 4. Check the type High School Junior College, College or University of School: Technical, Trade or Vocational Other (Specify) 5. (To be completed by all schools except junior colleges, colleges, or universities.) Enter the total clock hoursTotal hours per week per week the student is (was) scheduled to attend. Show any variations in scheduled attendance on the reverse. Knowing that anyone making a false statement or representation of a mate rial fact for use in determining a right to payment under the Black Lung Benefits Act, commits a crime punishable under Fede ral Law, I certify that according to this institutionsrecords the information given above is true. School Official Signature of School Official Title Date Form CM-981 Rev. June 1998<<<<<<<<<********>>>>>>>>>>>>> 2 Privacy 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. (2) The information will be used to determine eligibility for and the amount of benefits payable under the Act. (3) The information 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 410 or 20 CFR 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. (Disclosure of your social security number is voluntary; the failure to disclose such number will not result in the denial of any right, benefit or privilege to which an individual may be entitled.) Public Burden StatementPublic reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewinginstructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection ofinformation. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions forreducing this burden, 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 OFFICENote: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.