Operator Controversion {CM-970} | Pdf Fpdf Doc Docx | Official Federal Forms

Operator Controversion {CM-970}

Official Federal Forms/US Dept Of Labor/
Operator Controversion {CM-970} | Pdf Fpdf Doc Docx | Official Federal Forms

Operator Controversion Form

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<document>COURT COUNTY OFU.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation Operator Controversion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.OMB No. 1215-0058 Expires: 09-30-04 This information is authorized by the Black Lung Benefits Act (30 U.S.C. 901 at. seq.). This collection explains your reasons for not agreeing with the initial findings and is required to retain your rights to contest the findings in this black lung claim [20 CFR 725.413 (B) (3)].Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Miner's NameClaim NumberA. Controversion of LiabilityThis firm is not the responsible operator because:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .This 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 on or 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. FromLocation of Mine(State)(County)Name of Mine to 2. FromGREETINGS:Location of Mine(County)(State)WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,Other, Explanation: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., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)B. Controversion of Eligibility of ClaimantAttorney(s) forThe claim was not timely filed. The miner did/does not have pneumoconiosis. The miner was/is not totally disabled by pneumoconiosis. The miner's pneumoconiosis was not caused by his coal mine employment. The miner's death was not due to pneumoconiosis.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:Form CM-970 Rev. Dec. 1999American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OFThe following dependents of the claimant are not qualified:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.1. NameReasonCalendar No.2. NameJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Reason3. NameReasonC. Controversion of Benefit Amount. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The computed amount of the initial payment is incorrect. Our computation indicates it is $Explain your computation (Including augmentation for dependents):THE PEOPLE OF THE STATE OF NEW YORK TOD. Controversion of Other issues (Explain)GREETINGS: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.Notice:, one of the Justices of theThis firm intends to submit evidence in support of this controversion. (See 20 CFR 725.414 at. seq. for requirements regarding submission of evidence.)Court in Witness, Honorableday of, 20 County,Title Signature(Attorney must sign above and type name below)Date Name and Address of FirmAttorney(s) forOffice and P.O. AddressPublic Burden StatementTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:Public reporting burden for this collection of information is estimated to average 15 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 Mine Workers' Compensation, Room C3526, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. Note: Persons are not required to respond to this collection of Information unless It displays a currently valid OMB control numberAmerican LegalNet, Inc. www.USCourtForms.com</document>