Appeal Form

ECAB Docket No.
                                                                                  Official Use Only

                EMPLOYEES’ COMPENSATION APPEALS BOARD
                  APPLICATION FOR REVIEW (AB-1) FORM
                    PLEASE TYPE OR PRINT APPLICATION

1. Name of Appellant:
                             (First)                    (Middle)            (Last)
1a. Name of deceased employee, if applicable:

2. Date of OWCP Decision(s) Being Appealed:

NOTICE: YOUR APPEAL WILL BE SUBJECT TO DISMISSAL UNLESS YOU
    PROVIDE THE OWCP DECISION DATE YOU ARE APPEALING.

An Application for Review must be filed within 180 days following the date of the OWCP Decisi on(s)
being appealed. If your appeal is not timely filed, you must attach a statement with supporting
documentation establishing compelling circumstances which prevented timely filing.

3. Appellant’s Street Address:

  City, State, and Zip Code:

4. Appellant’s Telephone Number(s):

5. OWCP Case File (Claim) Number:

6. Briefly state the specific reasons for your disagreement with the Decision of the
OWCP: (Use additional sheets if needed.)




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 7. Is Oral Argument requested?             Yes      No
 If yes, your request will be granted or denied in the Board’s discretion pursuant to the Board’s Rules
 of Procedure (Code of Federal Regulations 20 C.F.R. § 501.5 (rev. 2008)). You must state the specific
 issue(s) to be argued and state in detail the specific reasons that an oral argument is necessary as part
 of your appeal. The issues and supporting statement need not be long, but they should be as cl ear
 and specific as possible. Should your request for oral argument be denied, the appeal will be decided
 on the record. (Use additional sheets if necessary.)




PLEASE NOTE: By requesting Oral Argument you are confirming that you will appear at
the date and time scheduled if the oral argument is granted. The Board does not pay for
travel, or any other expenses, related to attending oral argument. Evidence that was not
in the case record at the time of the decision(s) appealed to ECAB cannot be
submitted to the Board at oral argument.


  8. Appellant’s Signature:                                                  (Date)

 9. YOU DO NOT HAVE TO HAVE A REPRESENTATIVE IN ORDE R TO PURSUE
 YOUR APPEAL. IF A REPRESENTATIVE IS DESIGNATED, THEN HE OR
 SHE MUST SIGN THIS FORM CONSENTING TO REPRESENT YOU. My
 authorized representative for the purpose of this appeal is:

 Representative’s Name:

 Mailing Address:

 City, State, Zip Code:

 Telephone Number:

 10. Representative’s Signature:                                          (Date)

   If you have any questions concerning this form, call the Employees’ Compensation
     Appeals Board at 1-(866) 487-2365 or send a facsimile (fax) to the Board at (202)
    513-6833. To mail the form, address it to the Employees’ Compensation Appeals
     Board, Office of the Clerk, U.S. Department of Labor, 200 Constitution Avenue,
                       N.W. Room S5220, Washington, D.C. 20210.
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