Date

Case ID Number:

Employee Name:

Name

Address

Address

Dear Mr./Ms. Last Name:

This is regarding your claim for benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). On Date of Letter or Phone Call you advised us that you do not want to pursue a claim for impairment.

I would like to thank you for taking the time to consider our request to file for an award. Please note that your decision at this time does not relinquish your right to file a claim for impairment in the future. Therefore, we will not undertake further development for impairment at this time. Should you wish to pursue a claim in the future, please notify us in writing at the address above.

If you have any questions about your claim or other benefits available under this program, do not hesitate to call me, toll-free, at ( ) . If it is more convenient, you may visit one of our local resource centers for additional help.

Sincerely,

Printed Name

Claims Examiner