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.