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U.S. Department of Health and Human Services

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Staff Manual Guide 2310.3, Attachment F

 

 AMENDMENT TO 
HEALTH AND HUMAN SERVICES' EMPLOYEE EMERGENCY PAYMENT REQUEST, 
PROMISSORY REPAYMENT AGREEMENT, AND SALARY OFFSET AUTHORIZATION

 

I, ____________________________ certify that I have not received my salary for the pay period

ending _________ because _____________________________________________________________.

I request an extension of my emergency payment of $_________ dated ______________.

 

___________________________
Employee's Signature

___________________________
Date

___________________________
Agency/Office

___________________________
Room No.

___________________________
Phone No.

 

FINANCE OFFICE APPROVAL:

I hereby authorize an extension to this emergency payment.

 

____________________________________________
David R. Petak
Chief, Accounting Branch

____________________________________________
Date