I-2-6-95.Sample - Recording Storage Envelope

Last Update: 1/14/16 (Transmittal I-2-160)

FRONT OF RECORDING STORAGE ENVELOPE

Claimant's Name __________________ Claim Number __________________

Date and Time __________________ City _____________________________

ALJ __________________________ H _______________________________

Claimant Represented by ___________________________________________

Witnesses _________________________, _____________________________

Recording No._____ of _____