Get Department Of Labor Request To Be Selected As Payee Reset Office Of Workers '' Compensation

This guide provides a clear and supportive approach to completing the Department Of Labor Request To Be Selected As Payee for Black Lung benefits. By following these step-by-step instructions, users can ensure they fill out the required form accurately and efficiently.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to access the document online.
2. In the first section, enter the name of the coal miner in the designated field. Do not write in the space labeled 'Do Not Write In This Space'.
3. Next, provide the name of the beneficiary who is entitled to Black Lung benefits, along with their Social Security Number in the following fields.
4. Enter your name as the person requesting to become the payee, and include your case ID number.
5. Answer question 4 regarding your relationship to the beneficiary. If more space is needed, attach an additional sheet.
6. Indicate your reason for requesting payment of Black Lung benefits in question 4b. Again, feel free to use a separate sheet if needed.
7. If the benefits are currently being direct deposited, provide the bank name and account details in section 4c. Include the account number and routing number.
8. Respond to question 5 about any felony convictions and provide any necessary explanations.
9. Answer question 6, confirming that you will promptly notify the Department of Labor of any changes that could affect benefit payments.
10. Proceed through the remaining questions regarding living situations, legal representatives, and physicians as specified in the form.
11. At the conclusion of the form, sign and date it, ensuring all information is accurate before submission.
12. Save changes, download, print, or share your completed form as necessary to ensure proper documentation.

Complete the document online to ensure timely processing of your request.