RC Checklist Cover Sheet
Date: _______________
To:
| DOL Jacksonville District Office | à | Attention: | __________________ | |
| DOL Denver District Office |
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| DOL Cleveland District Office |
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| DOL Seattle District Office |
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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 ________________________________