Sample Waiver

Case Number:

Employee:

Claimant:

Date of Decision:

U.S. Department of Labor, DEEOIC

P.O. Box 8306

London, KY 40742-8306

Dear Sir or Madam:

I, _______________________, being fully informed of my right to object to any of the findings of fact and/or conclusions of law contained in the Recommended Decision issued on my claim for compensation under the Energy Employees Occupational Illness Compensation Program Act, do hereby waive those rights.

_______________________

Signature

_______________________

Date