I-4-1-113.Exhibit - Pre-printed Routing and Transmittal Slip for Declarations

Last Update: 9/13/05 (Transmittal I-4-15)

TRANSMITTAL BY OFFICE OF
HEARINGS AND APPEALS

DATE: [Today's date]

TO:

[System generates address from Form Screen]

FROM: Office of Appellate Operations

              CCPRB [System generates CCPRB No.]

              5107 Leesburg Pike

              Falls Church, VA 22041-3200

BY:

(Claimant's Name and SSN)

[Claimant Name]

[SSN]

ATTACHMENT:

[System generates: DECLARATION]

[UNTIMELY / FAILURE TO EXHAUST / RES JUDICATA / “OTHER”]

REMARKS: