Form CM-910 Request To Be Selected As Payee

U.S. Department of Labor

Request To Be Selected As Payee
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Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

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I hereby request that the Black Lung benefits for the person or persons named in item (2) below be paid
to me. (If you are requesting that your own benefit payments be made directly to you instead of to
someone else on your behalf, enter your own name in item 2 and answer the questions on this form
with respect to yourself.) Disclosure of the Social Security Number is voluntary. The failure to disclose
this number will not result in the denial of any right, benefit or privilege to which you may be entitled.
1. Name of Coal Miner

Do Not Write In This Space

2. Name of beneficiary (the person entitled to Black Lung benefits)

Social Security Number

OMB No.: 1215-0166
Expires: 04-30-2009

Claim Number/SSN

3. Your name

4a. What is your relationship to the beneficiary? (if you need more space, attach a separate sheet of paper.)

4b. Why do you wish payment of Black Lung benefits to be made to you? (If you need more space, attach a separate sheet of paper.)

5. Have you ever been convicted of a felony?

If yes, explain below: (if you need more space, attach
a separate sheet of paper.)

Important: Question 6 (page 2) must be answered in all cases. Please review the following list of changes (events) which may affect Black
Lung payments and must be reported immediately.
- Receipt of or change in benefit payments made under any state Workers' Compensation program.
- Death of any beneficiary.
- Marriage of a person entitled to child's, widow's, parent's, brother's, or sister's benefits.
- Support payments received by a person entitled to parent's, brother's or sister's benefits.
- Legal adoption of any entitled child.
- Stopping of school attendance by a child, brother, or sister age 18 to 23.
- Improvement of a disabling condition of a disabled child, brother, or sister, 18 or older.
- Work performed as an employee or a self-employed person, by a miner, parent, brother, or sister.
- Your conviction of a felony.

Public Burden Statement
We estimate that it will take an average of 15 minutes to complete this collection of information, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to
respond is required to obtain or maintain a benefit. If you have any comments regarding these estimates or any other aspect of this collection
of information, including suggestions for reducing this burden, send them to the U.S. Department of Labor, Division of Coal Mine Workers' Compensation,
Room N3464, 200 Constitution Avenue, N.W., Washington, DC 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 number.

Form CM-910
Rev. April 2009

6. Do you agree to notify the Department of Labor promptly if any event listed occurs,
or any other event occurs that might affect the benefits of the person or persons
named in item 2?

7. Do you agree to return promptly any check for benefits received by you if the
person or persons named in item 2 is not entitled to it?

8 b. Name of person not living with you.
8a. Is the person or persons for whom you are asking payment
now living with you?

8 c. Name and address of person with whom he or she is living.
City

If "No," answer 8 b. and 8 c..

State

Zip

9a. Is there a legal representative (guardian, conservator, curator, etc.) of any benefici- 9 b. Name and address of the Legal Representative and type of Representative
-ary for whom you are asking payment?
City
State

Zip

If "Yes," answer 9 b. If "No," go on to item 10.
10a. Is the beneficiary under the care of a treating physician?

10 b. Name and address of Treating Physician
City
State

If "Yes," answer 10 b. If "No,'' go on to item 11.

Zip

11. Do you understand that all payments made to you on behalf of a beneficiary must be 12. Do you agree to notify the Department of Labor promptly if any beneficiary leaves
your custody, or when you no longer have responsibility for the welfare and care
spent for his present needs or (if not presently needed) saved for his future needs
of any beneficiary for whom you are asking payment?
and do you agree to use the benefits that way?

PRIVACY ACT STATEMENT
Section 901 of Title 30 to the US Code and 20 CFR 725.505 - 513 authorize collection of this information. The purpose of this information is to determine
whether the CM-910 applicant is eligible to be selected as the representative payee for a black lung beneficiary. Completion of this form is not mandatory;
however, failure to provide the information may result in your not being selected as a representative payee. Additional disclosures of this information may
be to: coal mine operators, who may be liable for benefit payments, as well as their insurers and legal representatives; state workers' compensation
agencies or the Social Security Administration, for the purpose of determining benefit payment offsets as specified under the Black Lung Benefits Act; the
Internal Revenue Service and other federal, state and local agencies for the purpose of conducting investigations related to the proper payment of benefits;
labor unions of which the beneficiary is a member for the purpose of exercising an interest in the Black Lung claim of its members as a part of their service
to the members, data processing contractors to the U. S. Department of Labor and debt collection agencies and credit bureaus for the purpose of collecting
overpayments that might be made to the beneficiary.
The penalty upon conviction for the misuse of benefits by a representative payee is a felony and/or imprisonment for up to five (5) years for the
first offense, pursuant to Public Law 98-460, 42 U.S.C. 408. A second offense is punishable by up to five (5) years of imprisonment and/or a fine
not exceeding $25,000. The court may also order restitution.

Signature Of Applicant

Signature (First name, middle initial, last name) (Write in ink)

Telephone Number

Mailing Address (include your ZIP Code)

Social Security Number

Date (Month, Day, Year)

City
State

County

Zip

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the applicant must sign below, giving their full addresses.

City

1. Signature of Witness

2. Signature of Witness

Address (No., St., City, State and ZIP Code)

Address (No., St., City, State and ZIP Code)

State

Zip

City

State

Zip