MEMORANDUM

DATE: mm/dd/yyyy

FOR {Name of DEEOIC Counsel}

Counsel for Energy Employees Compensation, Division of

Federal Employees and Energy Workers’ Compensation

FROM: {Name of requester or designee}

{Phone Number}

SUBJECT: {Routine/Terminal}

Power of Attorney review for {Employee/Survivor}

CASE ID: {Assigned Case ID Number}

PAYEE NAME: {John Doe}

POA STATE: {Jurisdictional state of origin of POA Example- Idaho}

Attached for your review is a Power of Attorney (POA) that purports to grant (Name of person granted POA) to act on behalf of the above named payee. Review the POA to decide if it is a properly executed document. Please forward your response to {designated national office staff person/s}, who will upload it into OIS.