Bulletin 04-02 Attachment 1

Employee Name:

Case File Number:

Docket Number (If applicable):

Claimant(s) Name(s)

(other than employee)

1)

2)

3)

4)

5)

TRANSFER FROM:

DISTRICT OFFICE

FINAL ADJUDICATION BRANCH

NATIONAL OFFICE

c Cleveland

c Denver

c Jacksonville

c Seattle

c Cleveland

c Denver

c Jacksonville

c Seattle

c Washington DC

c Director

c BPRP

TRANSFER TO:

DISTRICT OFFICE

FINAL ADJUDICATION BRANCH

NATIONAL OFFICE

c Cleveland

c Denver

c Jacksonville

c Seattle

c Cleveland

c Denver

c Jacksonville

c Seattle

c Washington DC

c Director

c BPRP

REASON FOR TRANSFER:

c FAB Review

c Policy/Procedure

c Reopen

c Medical

c Remand/Reversal

c Affirmation

c Solicitor

c Other:

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