CM-2970a Financial Summary for Self-Insured Operators

Financial Summary
for Self-Insured Operators

U.S. Department of Labor
Office of Workers' Compensation Programs
Division of Coal Mine Workers’ Compensation
www.dol.gov/owcp/dcmwc/index.htm
OMB No. 1240-0057
Expires: 11/30/2025

You must use this form to report the consolidated financial information set out below. OWCP will use this information to determine whether you
should be authorized (or continue to be authorized) to self-insure your liabilities under the Black Lung Benefits Act, 30 USC 901-944. All initial
and renewal applicants for self-insurance authority must submit the required information with their application. All operators currently authorized
to self-insure must likewise submit the required information on a schedule established by OWCP. Furnishing the information is required in order
to obtain or retain authorization to self-insure under the Black Lung Benefits Act. 30 USC 933(a)(1); 20 CFR 726.102, 726.112.
Parent company's name, address, and FEIN
FEIN:

Name:
Address:
State:

City:
Date of this report:

Reporting Period:

Cash

1

Cash and equivalents (excluding restricted amounts)

Debt

2a

Short-term borrowings

Income/
Cash Flow

Zip:

b

Current portion of long-term debt

c

Non-current portion of long-term debt

d

Current portion of capital lease obligations

e

Non-current portion of capital lease obligations

f

Other debt not reported above (e.g. notes payable)

g

Total debt (add lines 2a through 2f)

3

LTM Revenues

4

LTM Net income (enter a positive number for income or
a negative number for loss)

5a

LTM Interest expense (enter a positive number for expense)

b

LTM Interest income (enter a negative number for income)

c

Total LTM net interest expense (add lines 5a and 5b)

6

LTM Net income tax expense

7

LTM Depreciation, depletion, and amortization

8

LTM Non-operating income (enter a positive number for income or a negative
number for loss/expense)
LTM Earnings from discontinued operations (enter a positive number for
earnings or a negative number for loss/expense)

9
10

$

$

$

LTM Capital expenditures

Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to an information collection unless such collection
displays a valid OMB control number. We estimate that it will take an average 20 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering the necessary data, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this information collection process, including suggestions for reducing this
burden, to the U.S. Department of Labor, 200 Constitution Avenue, NW, Suite C3520-DCMWC, Washington, D.C. 20210 and reference the
OMB Control Number.
Please contact OWCP’s Division of Coal Mine Workers’ Compensation Responsible Operator Section at (202) 693-0046 should you
have any questions regarding this form.
CM-2017a

INSTRUCTIONS
Completion: Information stated on this form must be taken from the parent company's current consolidated financial statements.
Please report amounts to the nearest whole dollar.
Line 1:

Report total cash on hand and cash equivalents. Exclude any restricted amounts.

Line 2:

Report debt by the following categories:
a Short-term borrowings
b Current portion of long-term debt
c Non-current portion of long-term debt
d Current portion of capital lease obligations
e Non-current portion of capital lease obligations
f Other debt not reported above (e.g. notes payable)
g Add lines 2a through 2f and enter total on this line.

Lines 3 - 10:

“LTM” means Last Twelve Months. Thus, figures in these lines should reflect totals for the twelve

Line 3:

Report revenues for the last twelve months.

Line 4:

Report net income for the last twelve months. Note: Enter a positive number for income or

months prior to filing this report.

a negative number for loss.
Line 5:

Report interest in the following categories:
a Interest expense for the last twelve months. Note: Enter a positive number for expense
b Interest income for the last twelve months. Note: Enter a negative number for income
c Add lines 5a and 5b and enter the total on this line

Line 6:

Report net income tax expense over the last twelve months.

Line 7:

Report depreciation, depletion, and amortization over the last twelve months.

Line 8:

Report non-operating income for the last twelve months. Note: Enter a positive number for income or

Line 9:

Report earnings from discontinued operations for the last twelve months. Note: Enter a positive number

Line 10:

Report capital expenditures over the last twelve months.

a negative number for loss/expense.
for earnings or a negative number for loss/expense.

Submission: You may submit this form by e-mail (in .pdf format) or by postal mail to:
E-mail

RO.SELFINSURANCE@DOL.GOV

Hard copy:

U.S. Department of Labor
Division of Coal Mine Workers’ Compensation
200 Constitution Ave., N.W.
Suite C3520-DCMWC
Washington, DC 20210
ATTN: Responsible Operator Section

Form CM-2017a
Page 2