SAMPLE REPAYMENT AGREEMENT COVER LETTER

 

                                                                                    Employee: 

                                                                                    Case ID:

                                                                                    Claim ID:

 

Claimant Name

Address

 

Dear {Claimant Name}:

 

Enclosed is a Repayment Agreement pertaining to the overpayment of benefits in your Energy Employees Occupational Illness Compensation Program Act (EEOICPA or Act) claim. 

 

On [date], the Division of Energy Employees Occupational Illness Compensation sent you a final decision regarding an overpayment in your {Part B and/or E} claim in the amount of [$         ].  Thereafter, you requested that an installment plan be set up to repay the overpaid benefits, and a monthly repayment plan of   [$         ] was agreed upon. 

 

Please review the Repayment Agreement, sign and date it, and mail it to the following address:

 

DOL DEEOIC Central Mail Room

PO Box 8306

London, KY 40742-8306

 

A copy of the Repayment Agreement is provided for your records.  When you send the installment payments, please provide the Case ID on all checks or money orders, and notate that it is an overpayment refund.  Mail all payments to:

 

US DEPARTMENT OF LABOR

DEEOIC

200 Constitution Ave. NW, Room C-3320

Washington, DC  20210

 

If you have any questions, please contact this office at [PA phone number] or 202-693-0081.

 

Sincerely,

 

 

 

Name

Unit Chief for Policy,

Regulations and Procedures

DEEOI


Sample Repayment Agreement

 

                                                                                    Employee: 

                                                                                    Claimant: 

                                                                                    Case ID: 

 

REPAYMENT AGREEMENT

 

On [date], the Division of Energy Employees Occupational Illness Compensation sent {Claimant name} a final decision regarding an overpayment in {his or her} {Part B and/or E} claim for benefits in the amount of [$    ]{Claimant name} requested that an installment repayment plan be set up for monthly payments in the amount of [$       ].  The installment payments will begin [date], and will be due on the 1st of each month until paid in full, including accrued interest.

 

A check or money order is to be made payable to the “U.S. Dept. of Labor, OWCP/DEEOIC”The Case ID is to be notated on all payments.  Mail the payments to:

 

US DEPARTMENT OF LABOR

DEEOIC

200 Constitution Ave. NW, Room C-3320

Washington, DC  20210

 

I agree to repay the overpayment at stated in this Repayment Agreement. 

 

 

Claimant:  ____________________________                  Date: ____________

                      [Claimant Name]

 

Approved By: __________________________                Date: ____________

                                         ,Unit Chief

                        Policy, Regulations and Procedures

                        DEEOIC