1.  An overpayment of compensation was found in the above referenced case in the amount of {insert amount}.


It has been determined that the claimant does not have the present or prospective ability to pay the full amount of the claim within a reasonable period of time.  It has been further determined that there is no indication of fraud, the filing of a false claim, or misrepresentation on the part of the claimant or on the part of any other party having an interest in the claim.


(Adjust wording of paragraph 2 to fit circumstances.)


2.  On {insert date} DEEOIC advised the claimant that he was found (with/without) fault in the matter of the overpayment and was notified of the grounds for consideration of waiver and of his rights in the matter.  The claimant applied for waiver, and on {insert date} a final determination was made that claimant was with fault in the matter and was not entitled to consideration of waiver.


3.  Based on the information outlined above, it is hereby determined that full settlement of the claim for recovery of the overpayment shall be accepted in the amount of {insert amount}, which does not exceed $100,000 exclusive of interest and penalties, to be paid in the following manner and time:


{Describe payment terms}


4.  The claim for overpayment shall not be considered settled until full payment of {insert amount} has been made within the time and in the manner specified above.  The failure to make such payment shall result in the reinstatement of the full amount of the overpayment, less any amounts paid prior to default.


Given by me this       day of




Unit Chief for Policies,

Regulations and Procedures