Form EE-20 Letter to Claimant

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U.S. Department of Labor
Employment Standards Administration

Division of Energy Employees Occupational
Illness Compensation

File Number:
Payee Name:
Payee SSN:
Dear
I am pleased to inform you that your claim for benefits under the Energy Employees Occupational Illness Compensation
Program Act (EEOICPA) has been approved in the amount of: $ ______
Enclosed is the EN-20 Payment Information form which you, your legal guardian, or the person with power of attorney to
act for you must complete, sign and return to the regional Division of Energy Employees Occupational Illness
Compensation district office handling your claim. The person completing the EN-20 must submit it with an original
signature; we cannot accept faxes or other copied versions of the EN-20. The form must also be completed in permanent
ink and there can be no cross outs, trace-over marks, or other marks. Any alteration of the form, including the use of
white out or correction tape, will result in it being rendered unusable for purposes of issuing payment; this will cause a
delay in processing your payment.
If you elect to have the funds electronically transferred, please read the instructions carefully to avoid any delays. To
ensure your money arrives promptly and to the correct account, check with your financial institution before submitting the
form to verify the accuracy of the routing number and your account number.
The completed EN-20 should be returned within sixty (60) days of the date of this correspondence. Failure to return
the signed form within this period may be deemed a rejection of payment. If you have questions about
completing the EN-20 or you make a mistake or need another form, please contact your district office at
.
Sincerely,

Enclosure: EN-20
PRIVACY ACT: In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Energy Employees Occupational Illness

Compensation Program Act (42 U.S.C. 7384 et seq.) (EEOICPA) is administered by the Office of Workers’ Compensation Programs of the U.S. Department of Labor, which
receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has received will be used to determine eligibility for,
and the amount of, benefits payable under the EEOICPA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the
Federal agencies or other entities that employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim,
verify billing, and to consider other relevant matters. (4) Information may be given to Federal, state, and local agencies for law enforcement purposes, to obtain information
relevant to a decision under the EEOICPA, to determine whether benefits are being paid properly, including whether prohibited payments have been made, and, where
appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the Debt Collection Act. (5) Disclosure of the claimant’s social security
number (SSN) or tax identification number (TIN) is mandatory. The SSN or TIN, and other information maintained by the Office, may be used for identification, to support
debt collection efforts carried on by the Federal government, and for other purposes required or authorized by law. (6) Failure to disclose all requested information may
delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision.

NOTICE TO RECIPIENT: Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, OWCP,
Room S3524, 200 Constitution Avenue, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS. Persons are not required to complete this
form unless it displays a currently valid OMB number.

OMB No. 1215-0197

Expiration Date: 08/31/07

EE-20

Print
File Number:
Payee Name:
Payee SSN:

Authorized Payment
You have been found eligible to receive compensation in the amount of:
Authorizing Claims/FAB Examiner (signature):

Payment Options
If you choose to accept the authorized payment, we need to know if you want to receive the award by Electronic Funds Transfer (EFT) or by
Paper Check. Provide all of the requested information and mail this form to the regional Division of Energy Employees Occupational Illness
Compensation (DEEOIC) district office handling your claim within sixty (60) days from the date of this letter

I elect to receive my award by: (check one box only)
Electronic Funds Transfer (Option 1) – Provide the financial institution and account information requested in Option 1.
Paper Check (Option 2) – Provide the address information requested in Option 2.

Option 1 – Electronic Funds Transfer:

Provide all the financial institution and account information requested below. The
DEEOIC cannot accept wire numbers or issue EFT payments to brokerage firms or other financial institutions that have a third party
routing system. Check with your financial institution before submitting the form to ensure an EFT can be made directly to your account
and to verify the accuracy of all information provided in this section. Please print clearly.

Financial Institution Information
Name of Financial Institution:
Street Address: (P.O. Boxes not accepted)
City:
Telephone Number:

State:

(

Zip:

)

Account Information
Transfer funds to: (check one)

Checking Account – provide checking account number:
Savings Account – provide savings account number:

Name of ALL Person(s) Holding the Account:
Financial Institutions Nine (9) Digit Routing Number or ID#:

Option 2 – Paper Check: Provide the address where you want to receive the check.

The address you provide will be considered

as your payment address only. Please print clearly.

Street Address:

P.O. Box/Apt. #:

City:

State:

Zip:

Certification
I hereby certify that I have reported to DEEOIC any third party settlement I have received, any tort suit I have filed against a beryllium vendor or an atomic
weapons employer, any state workers’ compensation awards I have received, any information I have regarding survivors (if applicable), and any conviction for
fraud against this program or any other federal or state workers’ compensation program. I affirm that the information provided on this form is true and that the
method of payment is correct.
VERIFICATION STATEMENT FOR POWER OF ATTORNEY: I know that anyone who fraudulently conceals or fails to report information that would have an effect on
benefits, or who makes a false statement or misrepresentation of a material fact in claiming a payment or benefit under the EEOICPA may be subject to criminal
prosecution, from which a fine and/or imprisonment may result. As the power of attorney, my signature below serves to verify that, to the best of my knowledge
and belief, the power of attorney I have to act on behalf of the above-named claimant is still valid under the existing law in the state in which the claimant
executed the power of attorney, as of the date of my signature on the EN-20. I also affirm that the information provided on this form is true and that the method
of payment is correct.

(

)

Printed Name

Current Telephone Number

Signature

Date

EN-20

Instructions for Completing the EN-20
The EN-20 is used to collect financial information needed to pay compensation to an individual who has been found eligible for benefits under
the Energy Employees Occupational Illness Compensation Program Act. The beneficiary, his or her legal guardian, or the person with the power
of attorney to act for the beneficiary, must complete the form in permanent ink. The requested information must be completed in its entirety.
Any omission or alteration of the information will result in it being found invalid and another EN-20 will have to be completed. Contact the
district office handling your claim if you have any questions or need assistance completing the form.

Authorized Payment
The amount of compensation to be paid is listed in this section. The signature of the claims examiner or Final Adjudication Branch (FAB)
representative authorizing payment must be present.

Payment Options
You must first check the box electing one of the two options presented. Select to have your payment issued by Electronic Funds Transfer (EFT)
or paper check. Mark the box next to the selected method of payment and fill in the appropriate information.

OPTION 1 - ELECTRONIC FUNDS TRANSFER
EFT payments are generally viewed as more secure and expeditious than a paper check. However, you must provide certain information that
will allow the payment to be made to the account of your choosing. List the name, telephone number and address for the financial institution
processing the deposit. In the account information section, list the name of the primary account holder. The nine digit routing number and the
account number should be clearly printed in the appropriate sections. Do not use a deposit slip for purposes of reporting a routing or account
number; they do not necessarily contain valid routing numbers. You can obtain the routing number and checking account number off one of
your personal checks. Below is an example of where to find these numbers. However, to ensure the numbers are correct and to minimize any

potential delays in paying your award, you should confirm all information reported in the EFT section with your bank or financial institution
before submission.
John Q. Public
123 Main Street
Your Town, USA 12345-6789

201

Pay to the order of:

DOLLARS

MEMO

000056789
Routing/Transit
Number

1234567

0201

Account
Number

OPTION 2 – PAPER CHECK
A paper check can be issued to the address of your choosing. You must clearly mark that you want a paper check by checking the appropriate
box and providing the complete address where the payment is to be mailed. This will not affect any address maintained on file. If you have
moved and would like to request a permanent address change, you must submit a signed statement listing your new address in a separate
letter.

CERTIFICATION
If you have provided all the required information, print your name and sign and date the form. Submit the original EN-20 to the district office
handling your claim. You may make copies of the form for your records. If you are signing this form with “power of attorney” and have not
submitted the documents granting this authority, please submit them with the completed EN-20.

Most common reasons the form must be resubmitted:
•
•
•
•

No original signature
Did not check a box for payment options or checked both boxes
Faxed the form or submitted a copy
Did not complete the form in permanent ink

•
•
•

There are cross outs, trace-over marks, or other marks
Use of white out or correction tape
Incorrect routing or account numbers