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