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.