Certification by School Official

Certification by School Official                        Reset            Print         U. S. Department of Labor
                                                                                       Office of Workers' Compensation Programs
                                                                                       Division of Coal Mine Workers' Compensation



This report is authorized by the Black Lung Benefits Act (30 U.S.C. 901 et. seq.). While completion of this OMB No. 1240-0031
form is voluntary, we need your cooperation so that we may determine eligibility or payments due on a       Expires: 06/30/2026
claim for benefits under the Act. We would appreciate your prompt completion and return of this form.
An envelope requiring no postage is enclosed for your use. (Please see the Privacy Act statement before
completing this form.)

                                                                                           TWO FILING OPTIONS:
Name and Address of School (include branch or campus and division)                         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:
                                                                                              US Department of Labor
                                                                                              OWCP/DCMWC
                                                                                              PO Box 8307
                                                                                              London, KY 40742-8307
                                                                                              For Further Information call TOLL FREE: 1-800-347-2502

                                                                                           Telephone:                   Date:
    Attn: Registrar


Name of Miner on whose earnings claim is based (Last, First, Middle Initial)               DOL's Case ID Number:




Student
Name (Last, First, Middle Initial)                                                         Student's Date of Birth (mo, day, yr.)


Student identification Number used by School (If none, enter "None".)




Student's Expected Graduation Date


Complete All Items Below Giving Information Only For Period Indicated.
Attendance
    From (mo., day, yr.)                            To (mo., day, yr.)                                Present

Certification By School Official

1. Is the above student now in "Full-Time Attendance" According to the School's Standards and Practices? (For evening students use the
same standards applicable to day students.)       Yes             No
2. Was the above student in "Full-Time Attendance" According to the School's Standards and Practices during entire period entered above?

                           Yes             No (If "No", answer 3.)
3. If item 2 is answered "No" Please enter the beginning and ending dates (up to the present)         From (mo., day, yr.)
of the student's Full-Time Attendance. If none, enter "None".
(If more space is needed, use space on the reverse.)                                                  To (mo., day, yr.)

4. Check the type          Junior College, College or University         High School
of School:
                           Technical, Trade or Vocational                Other (Specify)

5. (To be completed by all schools except junior colleges, colleges, or universities) Enter the total clock hours per      Total hours per week
week the student is (was) scheduled to attend; show any variations in scheduled attendance on the reverse:

                                                                                                                                     Form CM-981
                                                                                                                                       Rev. 06/23
Knowing that a person who willfully makes any false or misleading statement or representation to obtain benefits or payments
under the Black Lung Benefits Act shall be guilty of a misdemeanor under 30 USC 941 and, on conviction, subject to a civil
money penalty or imprisonment for up to one year, or both, I certify that according to this institution's records the information
given above is true.

School Official

Phone Number:                                        E-mail Address                                                   Date




Signature of School Official                                          Title



                                                           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.

                                                                      Notice
If you have a disability, federal law gives you the right to receive help from the OWCP In the form of communication assistance,
accommodation(s) and/or modification(s) to aid you in the OWCP 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 of changes to
accommodate your disability. Please contact our office or your OWCP claims examiner to ask about this assistance.


                                                          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. 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-981 PAGE 2
                                                                                                                                 Rev. 06/23