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

Form ID:

OWCP EE-4

Control ID:

OMB Control No. 1240-0002

Expiration date:

Wed, 31 May 2028 - 23:59

Forms

OWCP EE-4: Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act

Note: Please read the instruction on page 3 before filling out this form. Please do not write in the shaded areas. Sign at the bottom of the second page. This form should not be completed by the person who is claiming benefits under EEOICPA. Use as many copies of Form EE-4 as necessary.