EE-20 Letter to Claimant

Employment History Affidavit for a Claim
Under the Energy Employees Occupational
Illness Compensation Program Act

U.S. Department of Labor

Employment Standards Administration
Office of Workers’ Compensation Programs

Note: This form is used to affirm the employment history for a claim filed under the Energy Employees
Occupational Illness Compensation Program Act (EEOICPA). Please do not write in the shaded areas.

Employee’s Information (Print clearly)

Submit

1. Employee’s Name (Last, First, Middle Initial)

OMB No. 1215-0197
Exp Date: 08/31/2007

Reset

2. Maiden/Former Name

Print

3. Social Security Number (If known)

Your Information (Print clearly)
4. Your Name (Last, First, Middle Initial)

5. Your Telephone Number(s)
a. Home:

(

)

-

b. Other:

(

)

-

c. Other:

(

)

-

6. Your Address (Street, Apt. #, P.O. Box)
(City, State, ZIP Code)

7. Your Relationship to the Employee (Check all that apply)
Work Associate

Spouse

Son/Daughter

Grandparent

Friend

Other:

Step-child

Parent

Employee’s Work History
In chronological order, starting with the most recent period of employment, describe your knowledge of the employee’s work history.
Provide as much identifying information as possible concerning the name of the employer and location (city & state) where the employee
performed the work.

Employer - 1 (Provide as much information as possible – if necessary attach a separate sheet)
Your knowledge of where
the employee worked
(spell out names)

Dates you know the
employee worked at
this facility

City/State:

Facility Name:
Building(s):
Contractor or sub-contractor name(s):

Start Date:

End Date:
Month

Day

Year

Occupation:
What type of work did the
employee do?

Month

Day

Year

Title:

Duties:

(Describe duties in detail)

Explain how you know the
employee’s work history

If you worked with the
employee during this period,
provide the following:

Your position and/or title:
Dates you worked with the employee:

From:

To:
Form EE-4
April 2005

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Employer - 2 (Provide as much information as possible – if necessary attach a separate sheet)
Your knowledge of where
the employee worked
(spell out names)

City/State:

Facility Name:
Building(s):
Contractor or sub-contractor name(s):

Dates you know the
employee worked at
this facility

Start Date:

End Date:
Month

What type of work did the
employee do?

Day

Year

Month

Occupation:

Day

Year

Day

Year

Title:

Duties:

(Describe duties in detail)

Explain how you know the
employee’s work history

If you worked with the
employee during this period,
provide the following:

Your position and/or title:
Dates you worked with the employee:

From:

To:

Employer - 3 (Provide as much information as possible – if necessary attach a separate sheet)
Your knowledge of where
the employee worked
(spell out names)

City/State:

Facility Name:
Building(s):
Contractor or sub-contractor name(s):

Dates you know the
employee worked at
this facility

Start Date:

End Date:
Month

What type of work did the
employee do?

Day

Year

Month

Occupation:

Title:

Duties:

(Describe duties in detail)

Explain how you know the
employee’s work history

If you worked with the
employee during this period,
provide the following:

Your position and/or title:
Dates you worked with the employee:

From:

To:

Declaration of the Person Completing this Form

Resource Center Date Stamp

Any person who knowingly makes any false statement, misrepresentation, concealment of fact of any
other act of fraud to obtain compensation as provided under EEOICPA or who knowingly accepts
compensation to which that person is not entitled is subject to civil or administrative remedies as well
as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine
or imprisonment or both. I affirm that the information provided on this form is accurate and true.

(Signature)

(Date)
Form EE-4
April 2005

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Form EE-4
This form is used to affirm the employment history of a living or deceased Energy employee. The EE-4 is an acceptable
format for providing an affidavit in support of an otherwise unsupported work history and can be filled out by anyone with
knowledge of a covered employee’s work history. Use as many EE-4 forms as needed. If you require additional space to
provide comments, attach a signed supplemental statement.

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 EEOICPA, and may be verified through computer
matches or other appropriate means. (3) Information may be given to the Federal agencies or private entities that
employed the employee 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 disclosed to physicians and
other health care providers for use in providing treatment or medical rehabilitation, making evaluations for the Office of
Workers’ Compensation Programs and for other purposes related to the medical management of the claim. (5)
Information may be given to Federal, state, and local agencies for law enforcement purposes, to obtain information
relevant to a decision under 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. (6) Disclosure of the claimant's social security number (SSN) or
tax identification number (TIN), if known, 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. (7) 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.

Public Burden Statement
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time
for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the
collection of information. If you have any comments regarding the burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, send them to the Office of Workers’ Compensation
Programs, U.S. Department of Labor, Room S3524, 200 Constitution Avenue, N.W., Washington, D.C. 20210. Do not
submit the completed claim form to this address. Completed claims are to be submitted to the appropriate district
office of the Office of Workers’ Compensation Programs. Persons are not required to respond to the information
collections on this form unless it displays a currently valid OMB number.

Form EE-4
April 2005

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