Request To Be Selected As Payee

Request To Be Selected As Payee                                                     U.S. Department of Labor
                                              Reset       Print                     Office of Workers' Compensation Programs
                                                                                    Division of Coal Mine Workers' Compensation

I hereby request that the Black Lung benefits for the person or persons named in item (2) below be paid to          OMB No: 1240-0010
me. (If you are requesting that your own benefit payments be made directly to you instead of to someone             Expires: 09/30/2027
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      Do Not Write In This Space
result in the denial of any right, benefit or privilege to which you may be entitled.
1. Name of coal miner



2. Name of beneficiary (the person entitled to Black Lung benefits)                                                 DOL's Case ID Number:



3. Your name



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




4a. 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.)




4b. If benefits are currently direct deposited, do you want them to continue going to the current account?           Yes        No    If no, provide:
     Checking                Savings

Bank Name                                                 Account #                                              Routing #
5. Have you ever been convicted of a felony?            Yes        No      If yes, explain below: (if you need more space, attach a separate sheet of paper.)




5a. Do you agree to annual financial reporting and unannounced visits of facilities?           Yes       No

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, spouse’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, 200 Constitution Avenue
  NW, Suite C3520-DCMWC, Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
  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:
                         US Department of Labor
                         OWCP/DCMWC
                         PO Box 8307
                         London, KY 40742-8307
  For further information call TOLL FREE: 1-800-347-2502
  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. October 2021
 6. Do you agree to notify the Department of Labor promptly if any event listed    7. Do you agree to return promptly any check for benefits received by you if
    occurs, or any other event occurs that might affect the benefits of the           the person or persons named in item 2 is not entitled to it?
    person or persons named in item 2?
          Yes       No                                                                      Yes         No


8. Is the person or persons for whom you are asking payment now living             8a. Name and address of person with whom he or she is living.
    with you?
          Yes       No                                                                                                            City
    If "No," answer 8a.                                                                                                           State         Zip

9. Is there a legal representative (guardian, conservator, curator, etc.) of any   9a. Name and address of the Legal Representative and type of Representative
    beneficiary for whom you are asking payment?
          Yes       No                                                                                                            City
                                                                                                                                  State         Zip
    If "Yes," answer 9a. If "No," go on to item 10.


 10. Is the beneficiary under the care of a treating physician?                    10a. Name and address of Treating Physician
          Yes       No
                                                                                                                                  City
    If "Yes," answer 10a. If "No,'' go on to item 11.
                                                                                                                                  State         Zip


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

                                                                    PRIVACY ACT STATEMENT
 The following information is provided in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. (1) Collection of this information is authorized by the Black
 Lung Benefits Act (30 U.S.C. 901, et. seq.) and implementing regulations (20 CFR 725.505-513). (2) The purpose of the 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 voluntary.
 Failure to provide the information may result in your not being selected representative payee. (3) This information may be used by other agencies or
 persons handling matters relating, directly or indirectly, to processing this form including liable coal mine operators and their insurance carriers; contractors
 providing automated data processing or other services to the Department of Labor; representatives of the parties to the claim; and federal, state or local
 agencies. This would include 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 relating to the payment of benefits; and debt collection agencies and credit bureaus for the purpose of
 collecting overpayments that might be made to the beneficiary. (4) Furnishing all requested information will facilitate accurate and timely determination of
 your eligibility to be selected as the representative payee for a Black Lung beneficiary. (5) 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.
 If you misuse benefits received as a representative payee, you may be convicted of a felony and fined under Title 18, U.S.C., or imprisoned for not
 more than 5 years, or both. The court may also order restitution. 42 U.S.C. 408, incorporated by 30 U.S.C. 923(b), 940.
  This section must be completed by the applicant (as opposed to the claimant) requesting to be selected as payee
Your signature (First name, middle initial, last name) (Write in ink)                             Your Telephone Number            Date (Month, Day, Year)


 Mailing Address (include your ZIP Code)                                                          List your Tax Identification Number

                                                         City                                     Social Security Number
                                                                                                                 -            -
                                                         State          Zip
                                                                                                  OR
 County                                                                                           Employer Identification Number
                                                                                                             -
 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.
 1. Signature of Witness                                                           2. Signature of Witness

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




 City                          State            Zip                                City                          State              Zip

                                                                                 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 staff to ask about this assistance.
                                                                                                                             CM-910 PAGE 2 (Rev. October 2021)