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U.S. Department of Health and Human Services
Indian Health Manual

Part 9, Chapter 4: Manual Exhibit 9-4-E

DEPARTMENT OF HEALTH AND HUMAN SERVICES
INSTALLMENT REPAYMENT AGREEMENT FOR
TRANSFERRING PERSONNEL - NOT TO EXCEED ONE YEAR

I, _______________________________, an employee of the Department of Health and Human Services, (Component Name) ________________________________, Acknowledge that as of (date including year) ___________.   I am indebted to the Department in the amount of $_____________________.  The debt consists of $___________________ principle; and accrued late payment charges of $_____________ interest, $_____________ administrative costs, and $_____________ penalty.  It arose as a result of my failure to repay the Department for (insert reason)

______________________________________________________________________________

______________________________________________________________________________

I hereby certify under penalty of perjury that I am financially unable to repay the debt in full in a single payment and request to be allowed to repay it in installments instead of having it offset from my salary or other funds that may be due me.

TERMS OF THE REPAYMENT AGREEMENT

Repayment of __________(Total Debt)__________(existing principle and all accrued to date last payment charges) with financing charges of $___________ percent (Private Consumers Rate in effect on date of agreement) in __________ equal payment of __________ payable on the dates listed below.  Financing interest over the length of the agreement will amount to:___________________.

PAYMENT DUE DATES

  1. ________
  2. ________
  3. ________
  4. ________
  5. ________
  6. ________
  7. ________
  8. ________
  9. ________
  10. ________
  11. ________
  12. ________

Payment must be made out to the Department of Health and Human Services and be received by the Finance Office at the address noted below on or before the payment due date.  Failure to pay any payment on time will result in this repayment agreement being declared in default.  Without further notice, any amount owed at the time of default will be referred to your employing agency for offset against your salary or other funds due you.

Department of Health and Human Services
(Insert mailing address)

______________________________________

______________________________________

______________________________________

I have read the above repayment agreement and I understand and agree to its terms and conditions as witnessed here by my signature.

__________________________________________________________________
Employee's Signature 		________________________________________
Date

__________________________________

Current Home Address

__________________________________

City, State, Zip Code

____________________________________________________________________________________________________________

FINANCE OFFICE APPROVAL

I hereby approve the repayment of the above cited debt by installments.

__________________________________________________________________
Approving Official's Signature 		________________________________________
Date

_____________________________________________

(insert name and title of approving official)

_____________________________________________

(insert location of approving official)