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Forms and Online Filings

Form number:

None

Form name:

MSHA Notification of Representative of Miners

Description:

A written declaration of an individual or union as the representative of miners for a given operator.

OMB Control Number and Expiration Date:

1219-0042; 6/30/2014

Filing Options:

MSHA Notification of Representative of Miners can be filed online.
File online

This notification may also be filed by submitting a printed letter to your local MSHA District Office.
District office contact information for coal mines
District office contact information for metal/nonmetal mines

Contact Information:

Questions regarding this form should be directed to MSHA at (877) 778-6055 or
zzMSHA-PEIRHelpDesk@dol.gov

Privacy Notice:

Privacy Notice

Legal Authority:

30 CFR Part 40.3

Burden Statement:

Public reporting burden for this collection of information estimated to average 10 minutes per response; including the time for reviewing instructions, searching existing data sources, gathering and maintaining the date need, and completing and reviewing the collection of information. Send comments regarding the collection of information, including suggestions for reducing this burden, to the Mine Safety & Health Administration, U.S. Department of Labor, Records Management Branch, 1100 Wilson Boulevard, Arlington, Virginia 22209-3939. Persons are not required to respond to this collection of information unless it displays a currently OMB Control Number.

Complete and File Form Online

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