RC Checklist Cover Sheet

Date:   _______________

To:

DOL Jacksonville District Office	à	Attention:	__________________
DOL Denver District Office
DOL Cleveland District Office
DOL Seattle District Office

The attached claim forms are submitted with supporting documentation.

Employee: ________________________    SSN: ________________________

Survivor: _________________________    SSN: ________________________

Enclosed documents include:

EE-1/EE-2	Birth Certificate
EE-3	Marriage License/Certificate
EE-4	Death Certificate
Authorization for Representation	Divorce Decree
EE-5 (s)	Power of Attorney Document
ORISE Printout	Adoption Records
Copy - Appendix H or 02-34 letter	SSA-581
Copy - Letter to DOE OPS Center	Social Security Records (brought in by claimant)
Copy – Letter to Corporate Verifier	Medical Records/Pathology Report
Claimant Employment Records	Other
Occupational History Questionnaire	Other
Occupational History Thank You Letter	Other

Resource Center Manager ________________________________