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Staff Manual Guide 2310.3, Attachment A

Emergency Payment Request

Claim No. _____________________________

Pay Period _________ Year _________

 

Name of Employee: __________________________________________________
Social Security No.: _________________________________________________
Office/Center: __________________________________________________

Mailing Symbol: ______________Telephone: _________________________
Bldg./Room No.: ________________________________________________

Reason for Application - check one:

  • Non delivery in mail _________
  • EFT omission ______________
  • Other (explain) ____________

______________________________________________________________
______________________________________________________________
______________________________________________________________

PROMISSORY REPAYMENT AGREEMENT

I understand that the amount advanced to me is a temporary loan only. I will make repayment in full upon receipt of my check. If I fail to make repayment within 30 days, I authorize the amount advanced to be withheld from a future salary payment. Failure to repay will also initiate interest and administrative charges required by the Federal Debt Collection Act of 1982, P.L. 97-385. I have also received, read, and understand the NOTICE OF REQUIREMENT TO REPAY EMERGENCY PAYMENT.

 

______________________________________________________________
Employee's Signature/Date

Timekeeper Name: _________________________________
Timekeeper No.: __________________
CAN No._________________________

Employee

  • Regular: __________
  • Overtime: _________
  • Other: ____________

Timekeeper Signature: 

 

_____________________________________________

Supervisor Signature: 

 

_____________________________________________

Payroll Liaison
  • Receipt pay statement 05340 $__________
  • Other calculation:

 

 

 

 

___________________________________________
P.L. Signature/Date

Cash Received: $______________________________

 

______________________________________________________
Employee's Signature/Date

Authorization Signature:

 

___________________________________________

Director, OFM or Chief, Acctg. Br./Date

Repaid Date: __________________Amount $_________________
C.D. No.______________________Amount $_________________
Schedule No. ______________________

 

Transmittal Number: 93-35

Date: 04/16/1993