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U.S. Department of Health and Human Services

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Staff Manual Guide 2310.3, Attachment E



John Doe
9876 Main Street
Anywhere, USA 12345


Dear Mr. Doe:

A check for an Employee Emergency Payment was issued to you on ______________, 19___ in the amount of $_______. Our records show that you have not repaid the Employee Emergency Payment in accordance with the terms of the Promissory Repayment Agreement dated ______________, 19___. If you have submitted payment, in full, please let us know as soon as possible by calling FTS 443-2014 to allow us to check our records and clear your account. If you do not respond within fifteen (15) days of the date of this letter, we will initiate offset action. 

In the event you have not already repaid us, you must submit payment for $__________, representing the full amount of the emergency payment of $__________, interest of $____________, and $___________ in administrative costs. Checks or money orders are to be made payable to the "Food and Drug Administration" and mailed to the address noted below. 

Department of Health and Human Services 
FDA Payroll Liaison 
HFA-124, Room 11-90 
5600 Fishers Lane 
Rockville, MD 20857 

If full payment is not received within thirty (30) days of the date of this notice, we will initiate recovery of this debt owed to the Government without further notice to you, by salary or other offset, as you agreed to in your request for an Employee Emergency Payment. Additional late payment charges will be assessed in the Promissory Repayment Agreement. 

Your prompt attention to this matter is greatly appreciated. If you have any questions, please call the Payroll Liaison Office at FTS 443-2014. 




David R. Petak 
Chief, Accounting Branch