Sample Waiver

File Number:

Employee:

Claimant:

Date of Decision:

 

Final Adjudication Branch

U.S. Department of Labor DEEOIC

Attn.: District Manager

FAB Address

City, State ZIP

 

 

 

Dear Sir or Madam:

 

I, _______________________, being fully informed of my right to object to any of the findings of fact and/or conclusions of law contained in the Recommended Decision issued on my claim for compensation under the Energy Employees Occupational Illness Compensation Program Act, do hereby waive those rights.

 

 

_______________________

Signature

 

 

_______________________

Date