• Decrease font size
  • Return font size to normal
  • Increase font size
U.S. Department of Health and Human Services

About FDA

  • Print
  • Share
  • E-mail

Staff Manual Guide 2310.3, Attachment B



1. I, _______ certify that I have not received my salary for the pay period ending ____________ because ___________________. I request an emergency payment of $________.

2. I understand that I am personally liable for repaying the Government. I agree to make full repayment within thirty (30) days of the date that the Employee Emergency Payment is issued. Repayment can be made by cash; check; or money order made payable to the "Food and Drug Administration" and delivered to: Payroll Liaison (Room 11-90, Parklawn Bldg.) for Headquarters employees or the field fiscal section for field employees.

3. I understand my failure to repay this emergency payment timely and in full subjects me to late payment interest charges, a administrative costs, and penalties (in addition to the actual emergency payment amount); and other collection actions as authorized by the Debt Collection Act of 1982 implemented by 45 CFR Part 30, and 5 CFR Part 550. Payment is considered timely only if full repayment is received by the Food and Drug Administration within thirty (30) days of the date that the Employee Emergency Payment is issued. I also understand that:

a. Interest is assessed at the Private Consumer Rate which is in effect on the date the Emergency Employee Payment is issued. Interest is assessed on thirty (30) day periods. A partial period is considered a full period;

b. Administrative costs of $________ are charged for each full or partial thirty (30) day period that repayment is late;

c. An additional late charge penalty of six percent (6%) is charged on repayments which are more than ninety (90) days late;

d. Delinquent accounts can be reported to consumer credit bureaus which will affect my credit rating; private collection agencies whose fee is an additional administrative cost charge; the Department of Justice for suit in Federal court; and

e. Delinquent accounts are subject to recovery by withholding the amounts owed from my salary, retirement fund, and/or any other funds due me.

4. I have read and understand the above and request an Employee Emergency Payment. I further understand that I must make full repayment within thirty (30) days and I hereby authorize the Food and Drug Administration to initiate payroll offset with the payroll office or offset any other funds due me for all or any part of the Employee Emergency Payment contained in the Promissory Repayment Agreement that has not been repaid within thirty (30) days of the date issued, to include all applicable interest, administrative costs, and penalty charges as described above without further notice to me.


Employee Signature ________________________________________________



Room No.__________________________________

Phone No._________________________________

Current Address: _________________________________________________________________________

Prior Address: _________________________________________________________________________
(Fill Out Only if Address Has Recently Changed)

Emergency Payment Issue Date: _____________________________________