Skip to content
MSHA-Forms and Online Filings

Form number: None
Form name: MSHA Notification of Representative of Miners
Description: A written declaration of any person or organization which represents two or more miners at a coal or other mine for the purposes of the Act.
OMB Control Number and
Expiration Date:
1219-0042; 6/30/2014
Filing Options: Form fill, print and mail or fax
File online
Change online filing registration information

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 MSHAhelpdesk@dol.gov
    Privacy Notice: Privacy Notice
    Legal Authority: 30 CFR 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, Office of Standards, Regulations and Variances, 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

  • Return to MSHA Online Forms Advisor Main Menu