Form CM-972 

Rev. Sep. 2023

1. In accordance with the provisions of the Black Lung Benefits Act (30 U.S.C. 901 at seq.), 33 U.S.C. 928 and the regulations of the U.S. Department of 

Labor governing the administration of such Act (20 CFR 725.365 et seq.), I the undersigned hereby make application for a representative's fee for my 

services rendered from

before the: (Check only one block)

to

U.S. Department of Labor 

Office of Worker's Compensation Programs 

Division of Coal Mine Workers' Compensation

Application for Approval of a Representative's 

Fee In a Black Lung Claim Proceeding 

Conducted by The U.S. Department of Labor

NOTE: No fee for services performed may be paid under this program unless the Information prescribed by existing 

regulations is provided to this office. 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.

OMB No. 1240-0011 

Expires: 10/31/2026

in the claim of:

7. Explain on a separate sheet the nature and 

extent of any unusual circumstances or any other 

relevant data which should be considered in 

approving your fee. (Note: As stated in 20 CFR 

725.365, no lay representative is entitled to a lien 

against the award.

8. Did you or your firm receive or request any 

fee for services rendered to the claimant in any 

claim for pneumoconiosis (black lung) benefits 

before any state or federal agency?

Yes No

If YES, show amount:

9. Did you request monies from this claimant to 

place in an escrow account or to use as expense 

advances?

and itemize on separate sheet. (See Reverse)

If YES, show amount:

Yes No

Certification: I certify that the fees and expenses listed in blocks 4 through 9 constitute the complete claim for representing this client during the period and 

before the adjudication official indicated in block 1. Any claim for fees or expenses for services rendered during a period or before an official other than the 

period and official indicated in block 1 will be submitted on a separate CM-972. I have made no agreement and will make no other claim (unless disclosed in 

block 8) which would entitle me to any portion of the proceeds the client may be awarded under the terms of any Act administered by the Office of Workers' 

Compensation Programs. I certify that I have furnished a copy of this application and any attachments to the person for whom the above services were 

performed and to all other parties in the claim. I certify that the information given by me on this application is true and correct to the best of my knowledge. I 

am aware that severe penalties, including fine and imprisonment, may be invoked under 33 U.S.C. 928(e) whenever any person receives an unauthorized fee 

for services rendered, or under 30 U.S.C. 941 whenever any person willfully makes a false or misleading statement or representation for the purpose of 

obtaining payment under 30 U.S.C. 901 et seq.

10. Signature of Representative

(Client's Name - Last, First, Middle Initial)

2. Miner's Name

District Director Administrative Law Judge Benefits Review Board Other (specify)

3. DOL’s Case ID Number

4. Services Rendered (Use blank sheet of paper if additional space is needed)

(a) Date Rendered (b) Itemized services rendered 

(See reverse side for instructions)

(c) Professional Status of Person 

Who Performed the Service

(d) Usual Billing Rate Per 

Hour at Time of Service

(e) Time to 

Nearest 1/4 Hour

Total Time Expended on Case During Period:

5. Miscellaneous Expenses DOCUMENTED RECEIPTS MUST BE ATTACHED (Use blank sheet of paper if additional space is needed)

(a) Date Rendered (b) Itemize unreimbursed expenses incurred in connection with claim (See Reverse) (c) Cost

Total Miscellaneous Expenses Incurred:

6. Total Fee Requested (Amount of fee requested for services rendered and expenses incurred during the period designated in block 1 and itemized in 

blocks 4 and 5):

12. Telephone No. (Include Area Code)

14. Representative's Social Security Number or IRS 

Identification Number

11. Date

13. Name and Address of Representative
Form CM-972 

Rev. Sep. 2023

Instructions for Completing CM-972 

Note: Applicants for representative fees may submit the requested information from Blocks 4, 5, and 9 on official letterhead, along with a 

signed form CM-972. 

Block 4 - Services Rendered 

Column (b) - Itemize the services rendered on behalf of the claimant, such as: attend conference, draft letter, prepare 

interrogatories, etc. 

Column (c) - Enter the professional status of the person who performed the services on behalf of the claimant, such as: attorney, 

paralegal, law clerk, lay clerk, lay representative, clerical, or other status (specify). 

Column (d) - Enter the customary billing rate per hour at the time of service for each person who performed services on behalf of 

the claimant. 

Block 5 - Miscellaneous Expenses 

Column (b) - Itemize reasonable unreimbursed expenses incurred by the representative or by an employee of the representative in 

establishing the claimant's case, e.g. travel expenses, long distance phone calls, etc. All available receipts or other 

documentation of expenses must be attached. Please add client's name, miner's name (if different), miner's Claim Number and 

representative's name to any attachments. 

Note: List the type and amount of any expenses for which you were reimbursed in this case:

Type of Expense Amount

Block 9 - Escrow Account/Expense Advances 

Indicate amount placed in an escrow account, and/or itemize amount paid by claimant to the representative for any expenses.

Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

Privacy Act Notice 

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) the Black Lung Benefits Act (BLBA) (30 U.S.C. 

901et seq.), as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of Labor, which receives and 

maintains personal information, relative to this application, on claimants and their immediate families; (2) information obtained by OWCP will be used to 

determine eligibility for benefits payable under the BLBA; (3) information may be given to other government agencies, coal mine operators potentially liable 

for payment of the claim or to the insurance carrier or other entity which secured the operator's compensation liability, contractors providing automated data 

processing services to the Department of Labor; and representatives of the parties to the claim; (4) information may be given to physicians or other medical 

service providers for use in providing treatment, making evaluations and for other purposes relating to the medical management of the claim; (5) information 

may be given to the Department of Labor's Office of Administrative Law Judges, or other person, board or organization, which is authorized or required to 

render decisions with respect to the claim or other matters arising in connection with the claim; (6) information may be given to Federal, state or local 

agencies for law enforcement purposes, to obtain information relevant to a decision under the BLBA, to determine whether benefits are being or have been 

paid properly, and where appropriate, to pursue administrative offset and/or debt collection actions required or permitted by law; (7) disclosure of the 

claimant's or deceased miner's Social Security Number (SSN) or tax identifying number (TIN) on this form is voluntary, and the SSN and/or TIN and other 

information maintained by the OWCP may be used for identification and for other purposes authorized by law; (8) failure to disclose all requested 

information, may delay the processing of this claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits; and (9) 

this information is included in a System of Records, DOL/OWCP-2 published at 81 Federal Register 25765, 25858 (April 29, 2016) or as updated and 

republished. 

Public Burden Statement 

Public reporting burden for this collection of information is estimated to average 42 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, 200 Constitution Avenue, N.W., Suite C3520-DCMWC, Washington, D.C. 20210. Note: Persons are not 

required to respond to this collection of information unless it displays a currently valid OMB control number. (DO NOT SEND THE COMPLETED 

FORM TO THIS OFFICE.) 

Notice 

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in 

the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of 

documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the 

limitations of your disability. Please contact our office or the claims examiner to ask about this assistance.

TWO FILING OPTIONS: 

1.To file electronically, submit completed form to the COAL Mine Portal: https://coalmine.dol.gov

2.To file by mail, send completed form to: 

U.S. Department of Labor 

 OWCP/DCMWC 

 PO Box 8307 

 London, KY 40742-8307 

 For Further Information call TOLL FREE: 1-800-347-2502