MEMORANDUM

 

 

 

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.