This form is for use by black lung litigants, representatives and attorneys when responding an administrative law judge's prehearing order requiring the submission of an evidentiary summary.

The form is designed specifically to apply to the new evidentiary limitations in black lung adjudications.

• Adobe PDF Format

This form is in Adobe Adobe Portable Document Format (PDF). Adobe software distributes a free Adobe Acrobat Reader for PDF files at its web site, and it is recommended that users of this form obtain Version 5.0 or later of the reader.
For information about accessibility of Adobe PDF documents, see access.adobe.com

You can fill out the form on-line in Adobe Acrobat, Acrobat Approval, or Acrobat Reader. Please note that only Adobe Acrobat and Adobe Approval permit you to save a completed form to your hard drive.

The information you type on these forms is not transmitted over the Internet. You must print the completed form, and mail it to the trial judge.