U.S. Department of Labor
Office of Workers' Compensation Programs
P.O. Box 8300
London, KY 40742-8300

	RE:	Claimant:  ______________________________

		Date of Birth:  ___________________________

		Social Security No.:  ______________________

		Date of Injury:  __________________________

		OWCP File No.:  ___-______________________

	I hereby authorize Attorney Jacqueline Shanahan to inspect and 
        copy any and all of my Federal Employee's Compensation Act
        Claim Files, including, but not limited to ____-__________________.

	I am willing that a photocopy and/or a fax copy and/or an e-mail 
        copy of this authorization be accepted with the same authority as
        the original.  I request that you provide the copy of the file(s) 
        without fee.

					__________________________________
						           Signature

					__________________________________
						         Printed Name

HOME ADDRESS: 	 ______________________________________
		
 		 ______________________________________

TELEPHONE NUMBERS:       HOME:   __________________________ 
				           
			 CELL:   __________________________

NAME OF EMPLOYER:_____________________________________

E-MAIL ADDRESS:	______________________________________
			(please print legibly)