U.S. Department of Labor

Office of Workers' Compensation Programs 

Division of Coal Mine Workers' Compensation

OPERATOR RESPONSE TO 

SCHEDULE FOR SUBMISSION OF

ADDITIONAL EVIDENCE

Miner's Name Claimant's Name Claim Number OMB No. 1240-0033 

Expires: 10/31/2026

Responsible Operator's Name Insurer's Name Policy No.

This report is authorized by the Black Lung Benefits Act 30 U.S.C. 901 et seq. and the regulations of the U.S. Department of Labor governing the 

administration of such Act (20 CFR 725.412). 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

The named responsible operator:

Agrees it is the responsible operator within the meaning of the Black Lung Benefits Act, liable for 

any benefits to which the claimant is finally determined to be entitled.

Disagrees with its designation as the responsible operator liable for this claim.

If you disagree, the schedule for the submission of additional evidence advises you of the time period within which you may submit evidence relevant 

to your liability, subject to the limitations imposed by 20 C.F.R. 725.408(b)(2). Absent extraordinary circumstances, 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

The named responsible operator:

Accepts the Claimant's entitlement to benefits.

Contests the Claimant's entitlement to benefits.

If you do not accept the claimant’s entitlement to benefits, the schedule for the submission of additional evidence will advise you of the time 

period within which you may submit evidence relevant to the claimant’s entitlement. If you enter no response in this section, you will be deemed 

to have contested the claimant’s entitlement to benefits.

Name and Address of Firm Completing Form Name of Person Completing Form

Title

Signature Date

Form CM-2970 

Rev. Oct. 2023

Two Filing Options:

1. To file electronically, submit completed form to the COAL Mine Portal: 

https://coalmine.dol.gov

 

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

OWCP/DCMWC/CMR Correspondence 

PO Box 8307 

London, KY 40742-8307 

For Further Information call TOLL FREE: 1-800-347-2502 
Form CM-2970 

Rev. Oct. 2023 Page 2

Privacy Act Statement 

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. 

901 et 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 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 Mine 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.