**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

![](media/image1.png){width="1.1305555555555555in"
height="0.7243055555555555in"}PROGRAM SUPPORT CENTER

### STUDENT LOAN REPAYMENT PLAN

**(PROGRAM SUPPORT CENTER (PSC) AND**

**PSC-SERVICED HHS COMPONENTS)**

**PURPOSE**

Section 5379 of Title 5, United States Code, and Part 537 of Title 5,
Code of Federal Regulations (CFR), establish the statutory and
regulatory authority for the use of student loan repayment of up to
\$6,000 per year with a maximum of \$40,000 per employee as a
recruitment or retention incentive. This plan provides the parameters
for implementation of the incentive for Department of Health and Human
Services (HHS), Operating Divisions (OPDIVs) and Staff Divisions
(STAFFDIVS) that are serviced by the PSC, Human Resources Service
(HRS).PSC-serviced activities may develop supplements to this plan, but
such supplementation must be coordinated with PSC.

**REFERENCES**

The Office of Personnel Management (OPM) has published reference
materials on the Federal Student Loan Repayment Program on its Office of
Compensation Administration website at
<http://www.opm.gov/oca/pay/StudentLoan>. The materials include: (1)
general information about the Federal Student Loan Repayment Program;
(2) Student Loan Repayment Program Questions and Answers; (3) Student
Loan Repayment Program Questions and Answers on Tax Liability; (4) 5 USC
5479 (the law establishing the Program); and (5) 5 CFR Part 537 (the
regulations implementing the Program). Copies of these documents will
also be available from HRS/PSC. This plan should be read in conjunction
with these references, especially 5 CFR 537 and the Questions and
Answers.

**APPLICABILITY**

This plan applies to any HHS organization that receives human resources
services from HRS/PSC, here after collectively referred to as
PSC-serviced activities.

**ELIGIBILITY**

Repayment of student loans is limited to those for outstanding federally
insured loans made by educational institutions or banks and other
private lenders as authorized by the Higher Education Act of 1965 and
the Public Health Service Act. A PSC-serviced activity may offer student
loan repayment to facilitate the recruitment or retention of highly
qualified employees who meet the eligibility criteria established in 5
CFR 537.104.

The incentive may be paid provided there is a written determination by
the approving official designated in supplementation to this plan, that,
in the absence of student loan repayment, the PSC-serviced activity
would encounter difficulty in filling the position or retaining an
employee in that position. Determinations for recruitment purposes must
be made before the employee enters on duty. Determinations for retention
purposes must be based on the qualifications of the employee or the
special need of the agency for the employee's service, and that, in the
absence of offering loan repayments, the employee would be likely to
leave the Federal service. At the discretion of the approving official,
this authority may be used to repay student loans on which the employee
has defaulted. When selecting employees to be recipients, the
PSC-serviced activity shall consider both equitable treatment and
diversity of the workforce.

> **NOTE:** Employees receiving a Physicians' Comparability Allowance
> (PCA) under 5 CFR 595.105(e) are eligible for student loan repayment.
> However, the PCA amount must be reduced by an amount equal to any loan
> repayment assistance received under the program.

**AUTHORITY AND USE**

Heads of the OPDIVs and STAFFDIVs have the authority to approve the
repayment of student loans, and may further delegate this authority.
Prior to approval, the written determination must be reviewed by PSC/HRS
to verify that the employee and the loan meet the criteria established
by 5 CFR 575.The request and approval form included as attachment 3 must
be used for documenting reviews and approval.

Student loan repayment may be used for **recruitment** any time the
OPDIV or STAFFDIV can demonstrate that the potential employee has skills
that have been historically difficult to find and that, absent the use
of student loan repayment, the potential employee will likely seek
employment outside the Federal government.

Student loan repayment may be used for **retention** any time the OPDIV
or STAFFDIV can demonstrate that the employee has high or unique
qualifications that are essential to the agency, the employee fills a
special need of the agency and a replacement would require extensive
training and/or recruitment, and that, absent the use of student loan
repayment, the employee will likely leave HHS for employment outside the
Federal government.

**CRITERIA**

Criteria that must be met or considered in authorizing loan repayments
include the size and timing of the payment and budget considerations. In
supplements to this plan, PSC serviced activities may include
activity-specific criteria for determining repayments to be authorized.

In determining size of the repayment, the OPDIV or STAFFDIV should
consider the type of position occupied by the employee; the difficulty
in filling the position; the level of knowledge, skill, or ability
possessed by the employee; and any other factor considered relevant by
the approving official. Additional considerations may be described in
OPDIV/STAFFDIV supplements to this plan.

For PSC-serviced activities, the payment will be a one-time, after-tax,
lump sum payment to the credit or in each year that the employee is
deemed eligible and for which the payment is approved.

The OPDIV/STAFFDIV will ensure the availability of funds prior to
authorizing any student loan payment.

**SERVICE AGREEMENT**

Before any student loan repayment may be made, the employee must sign a
written agreement *(page 3)* requiring a minimum of 3 years employment
with the OPDIV or STAFFDIV making the payment. Additional payments made
during the 3-year service agreement do not require an extension of the
agreement. For each payment made beyond the 3-years service agreement,
one additional year of service is required.

The service agreement period begins when the first payment is made to
the holder of the loan. Additional conditions are included in the
attached service agreement. Employees who do not complete periods of
service under the terms of the service agreement are subject to the debt
collection process. In addition to waivers authorized by 5 CFR 537,
waivers may be considered when an employee accepts a position in a
different OPDIV or STAFFDIV, when an employee is separated by death or
disability retirement, or in other cases where the approving authority
determines that debt recovery would be against equity and good
conscience.

**PROCEDURES**

In order to process the reimbursement request; the following documents
must be submitted to HRS/PSC:

-   approved written determination that the student loan repayment is
    necessary.

-   Outstanding Loan Information *(page 4)*

-   signed Service Agreement; and

-   a copy of a statement from the employee's lending institution
    verifying the indebted\
    amount as well as the account and EFT routing numbers.

**DOCUMENTATION AND RECORDKEEPING**

The final, approved written determination, the signed service agreement,
and a copy of the SF 50 will be maintained in the PSC/HRS for a period
of 3 years following completion of the required service or until
completion of a formal OPM evaluation of the program, whichever comes
first. The SF-50 will be also filed on the permanent side of the
employee's Official Personnel Folder, and the Service Agreement will be
filed on the temporary side.

For purposes of this program, PSC established Nature of Action Code
9490, Student Loan Reimbursement, with Legal Authority Code ZLM/5 USC
5379. The SF-50 will show the beginning of the current pay period as the
effective date, the total amount of the reimbursement in Block 20, and
the following statement in the remarks section: \"Reimbursement total
amount \$ [     ]{.underline} .\"

**WITHHOLDING AND POSTING LOAN REPAYMENT**

Federal income tax withholding due on supplemental wages is calculated
under the flat rate method. The correct amount of\
Federal income tax withholding is calculated by taking a flat 28 percent
of the supplemental wages. State taxes are\
calculated based on the employee's current withholdings. Social Security
tax and Medicare tax withholdings are calculated at\
the usual rates and are in addition to both the 28 percent Federal
income tax withholding and the appropriate state income\
tax withholdings. The loan repayment is reported as Wages in Box 1 of
Form W-2, Wage and Tax Statement, and as\
Medicare Wages in Box 5 of Form W-2. The repayment is also reported as
social security wages in Box 3 of Form W-2.

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

PROGRAM SUPPORT CENTER

**STUDENT LOAN REPAYMENT SERVICE AGREEMENT**

<table>
<colgroup>
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 14%" />
<col style="width: 3%" />
<col style="width: 15%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 17%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="7"><p>NAME <em>(Print or Type - First, Last, MI)</em></p>
<p>     </p></td>
<td colspan="4"><p>SOCIAL SECURITY NUMBER</p>
<p>     </p></td>
<td colspan="3"><p>OPDIV/STAFFDIV</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="14">In consideration of the student loan repayment benefit
for which I qualify under 5 U.S.C. 5379 as implemented by the<br />
regulations of the U.S. Office of Personnel Management (5 CFR, Part
537), the policies of the Department of Health and<br />
Human Services, and the</td>
</tr>
<tr class="odd">
<td colspan="10">     </td>
<td colspan="4">, I hereby agree:</td>
</tr>
<tr class="even">
<td colspan="14"></td>
</tr>
<tr class="odd">
<td colspan="14"></td>
</tr>
<tr class="even">
<td colspan="2"><strong>1.</strong> To serve in</td>
<td colspan="6">     </td>
<td colspan="6">for 3 years <em>(initial contract or 1 year
extensions)</em>.</td>
</tr>
<tr class="odd">
<td colspan="5"><strong>2.</strong> The amount of the student loan
repayment benefit is $</td>
<td colspan="6">     </td>
<td colspan="3"><em>(up to $6,000)</em>. The payment</td>
</tr>
<tr class="even">
<td colspan="14"><blockquote>
<p>received by my financial institution will not reflect amount of the
repayment benefit as stated above. This repayment<br />
benefit is taxable. I understand that commitment to repay my loan is for
one year, subject to yearly extensions.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="14"><strong>3.</strong> If the agency provides student loan
repayment benefits in the 2nd or 3rd years of the agreement, I am only
obligated to<br />
serve the three years as stipulated by this agreement.</td>
</tr>
<tr class="even">
<td colspan="14"><strong>4.</strong> If the agency provides student loan
repayment benefits beyond 3 years, I am obligated to serve one
additional year for<br />
each payment made.</td>
</tr>
<tr class="odd">
<td colspan="4"><strong>5.</strong> The service agreement is
effective</td>
<td colspan="2">     </td>
<td colspan="3">through</td>
<td colspan="4">     </td>
<td>.</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"><em>(mm/dd/yy)</em></td>
<td colspan="3"></td>
<td colspan="4"><em>(mm/dd/yy)</em></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="14"><strong>6.</strong> This service agreement in no way
constitutes a right, promise, or entitlement for continued employment
or<br />
noncompetitive conversion to the competitive service. That acceptance of
this agreement does not alter the conditions<br />
or terms of my employment; accordingly, this agreement will not preclude
nor limit the Agency from effecting personnel<br />
actions as may be appropriate.</td>
</tr>
<tr class="even">
<td colspan="14"><ol start="7" type="1">
<li><p>That in the event I voluntarily leave HHS, or in the event that I
am involuntarily separated for misconduct or performance<br />
before completing the agreed upon period of service, I will be indebted
to the Federal Government and must reimburse<br />
HHS for the full amount of any student loan repayment benefits received
under this service agreement.</p></li>
<li><p>I am responsible for making loan payments on the portion of the
loan that continues to be my responsibility.</p></li>
<li><p>The student loan repayment benefits made do not exempt me from my
responsibility and/or liability for the loan.</p></li>
<li><p>I am responsible for any income tax obligation resulting from the
student loan repayment benefit.</p></li>
</ol></td>
</tr>
<tr class="odd">
<td><strong>11.</strong> HHS/</td>
<td colspan="2">     </td>
<td colspan="11">is not responsible for any late fees assessed by the
lender if the student loan repayment</td>
</tr>
<tr class="even">
<td colspan="14"><blockquote>
<p>benefit is not received on time.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="14"><strong>12.</strong> The student loan repayment
benefits made on my behalf from the Federal Government have/will not
exceed the<br />
maximum amount of $40,000.</td>
</tr>
<tr class="even">
<td colspan="14"><strong>13.</strong> Other condition(s) agreed to by
employee and the OPDIV:</td>
</tr>
<tr class="odd">
<td colspan="14"><blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="14"><strong>I AGREE TO THE TERMS OF THIS SERVICE
AGREEMENT</strong></td>
</tr>
<tr class="odd">
<td colspan="14">SIGNATURE</td>
</tr>
<tr class="even">
<td colspan="12"><p>NAME <em>(Print/Type)</em></p>
<p>     </p></td>
<td colspan="2"><p>DATE</p>
<p>     </p></td>
</tr>
</tbody>
</table>

DEPARTMENT OF HEALTH AND HUMAN SERVICES\
PROGRAM SUPPORT CENTER

STUDENT LOAN REPAYMENT SERVICE AGREEMENT\
OUTSTANDING LOAN INFORMATION

+-----------------------------------+---+-----+----+---+-----------------+
| NAME *(Print or Type - First,     |   |     |    | S |                 |
| Last, MI)*                        |   |     |    | O |                 |
|                                   |   |     |    | C |                 |
|                                   |   |     |    | I |                 |
|                                   |   |     |    | A |                 |
|                                   |   |     |    | L |                 |
|                                   |   |     |    | S |                 |
|                                   |   |     |    | E |                 |
|                                   |   |     |    | C |                 |
|                                   |   |     |    | U |                 |
|                                   |   |     |    | R |                 |
|                                   |   |     |    | I |                 |
|                                   |   |     |    | T |                 |
|                                   |   |     |    | Y |                 |
|                                   |   |     |    | N |                 |
|                                   |   |     |    | U |                 |
|                                   |   |     |    | M |                 |
|                                   |   |     |    | B |                 |
|                                   |   |     |    | E |                 |
|                                   |   |     |    | R |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| **NOTE:** The following           |   |     |    |   |                 |
| information is required for each  |   |     |    |   |                 |
| lender of loan(s) being           |   |     |    |   |                 |
| considered under the Student      |   |     |    |   |                 |
| Loan\                             |   |     |    |   |                 |
| Repayment Program.                |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| **LOAN INFORMATION \***           |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| NAME OF THE FEDERALLY FUNDED LOAN |   |     |    |   |                 |
| RECEIVED *(Federal Stafford Loan, |   |     |    |   |                 |
| Federal Plus Loan, Federally      |   |     |    |   |                 |
| Insured Student Loan, etc.)*      |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| DATE LOAN WAS OBTAINED            | R |     |    |   |                 |
|                                   | E |     |    |   |                 |
|                                   | M |     |    |   |                 |
|                                   | A |     |    |   |                 |
|                                   | I |     |    |   |                 |
|                                   | N |     |    |   |                 |
|                                   | I |     |    |   |                 |
|                                   | N |     |    |   |                 |
|                                   | G |     |    |   |                 |
|                                   | B |     |    |   |                 |
|                                   | A |     |    |   |                 |
|                                   | L |     |    |   |                 |
|                                   | A |     |    |   |                 |
|                                   | N |     |    |   |                 |
|                                   | C |     |    |   |                 |
|                                   | E |     |    |   |                 |
|                                   | O |     |    |   |                 |
|                                   | F |     |    |   |                 |
|                                   | L |     |    |   |                 |
|                                   | O |     |    |   |                 |
|                                   | A |     |    |   |                 |
|                                   | N |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   | \ |     |    |   |                 |
|                                   | $ |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| ACCOUNT NUMBER FOR ELECTRONIC     | R |     |    |   |                 |
| FUND TRANSFER (EFT)               | O |     |    |   |                 |
|                                   | U |     |    |   |                 |
|                                   | T |     |    |   |                 |
|                                   | I |     |    |   |                 |
|                                   | N |     |    |   |                 |
|                                   | G |     |    |   |                 |
|                                   | T |     |    |   |                 |
|                                   | R |     |    |   |                 |
|                                   | A |     |    |   |                 |
|                                   | N |     |    |   |                 |
|                                   | S |     |    |   |                 |
|                                   | I |     |    |   |                 |
|                                   | T |     |    |   |                 |
|                                   | N |     |    |   |                 |
|                                   | U |     |    |   |                 |
|                                   | M |     |    |   |                 |
|                                   | B |     |    |   |                 |
|                                   | E |     |    |   |                 |
|                                   | R |     |    |   |                 |
|                                   | F |     |    |   |                 |
|                                   | O |     |    |   |                 |
|                                   | R |     |    |   |                 |
|                                   | E |     |    |   |                 |
|                                   | F |     |    |   |                 |
|                                   | T |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| **\*** An official                |   |     |    |   |                 |
| document/letter by the loan       |   |     |    |   |                 |
| institution providing the above   |   |     |    |   |                 |
| Loan Information must be          |   |     |    |   |                 |
| attached.                         |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| **LENDING INSTITUTION**           |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| NAME OF LENDING INSTITUTION       |   |     |    |   |                 |
| *(holder of the loan, i.e., bank, |   |     |    |   |                 |
| educational institution, etc.)*   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| ADDRESS                           |   |     | T  |   |                 |
|                                   |   |     | EL |   |                 |
|                                   |   |     | EP |   |                 |
|                                   |   |     | HO |   |                 |
|                                   |   |     | NE |   |                 |
|                                   |   |     | NU |   |                 |
|                                   |   |     | MB |   |                 |
|                                   |   |     | ER |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     | (  |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     | )  |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| CITY                              |   | ST  |    |   | ZIP CODE        |
|                                   |   | ATE |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| **SERVICING AGENT**               |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| NAME OF SERVICING AGENT *(if      |   |     |    |   |                 |
| different from **Lending          |   |     |    |   |                 |
| Institution** to whom payments    |   |     |    |   |                 |
| are sent)*                        |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| ADDRESS                           |   |     | T  |   |                 |
|                                   |   |     | EL |   |                 |
|                                   |   |     | EP |   |                 |
|                                   |   |     | HO |   |                 |
|                                   |   |     | NE |   |                 |
|                                   |   |     | NU |   |                 |
|                                   |   |     | MB |   |                 |
|                                   |   |     | ER |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     | (  |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     | )  |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| CITY                              |   | ST  |    |   | ZIP CODE        |
|                                   |   | ATE |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| **AUTHORIZED OFFICIAL FOR THE     |   |     |    |   |                 |
| LENDING INSTITUTION**             |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| NAME                              |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| TITLE                             |   |     | T  |   |                 |
|                                   |   |     | EL |   |                 |
|                                   |   |     | EP |   |                 |
|                                   |   |     | HO |   |                 |
|                                   |   |     | NE |   |                 |
|                                   |   |     | NU |   |                 |
|                                   |   |     | MB |   |                 |
|                                   |   |     | ER |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     | (  |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     | )  |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| **FEDERAL TAX INFORMATION**       |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+
| FEDERAL TAX IDENTIFICATION NUMBER |   |     |    |   |                 |
| OR EMPLOYER IDENTIFICATION NUMBER |   |     |    |   |                 |
| (EIN)                             |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
|                                   |   |     |    |   |                 |
+-----------------------------------+---+-----+----+---+-----------------+

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

PROGRAM SUPPORT CENTER

REQUEST FOR AND APPROVAL OF STUDENT LOAN REPAYMENT BENEFIT\
UNDER THE STUDENT LOAN REPAYMENT PROGRAM (5 U.S.C. 5379)

+---------------------------+---+-----+---------+----+-----+------------+
| NAME *(Print or Type -    |   |     |         |    | SOC |            |
| First, Last, MI)*         |   |     |         |    | IAL |            |
|                           |   |     |         |    | SE  |            |
|                           |   |     |         |    | CUR |            |
|                           |   |     |         |    | ITY |            |
|                           |   |     |         |    | NUM |            |
|                           |   |     |         |    | BER |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
+---------------------------+---+-----+---------+----+-----+------------+
| TITLE                     | S |     |         | TY |     |            |
|                           | E |     |         | PE |     |            |
|                           | R |     |         | OF |     |            |
|                           | I |     |         | A  |     |            |
|                           | E |     |         | PP |     |            |
|                           | S |     |         | OI |     |            |
|                           | / |     |         | NT |     |            |
|                           | G |     |         | ME |     |            |
|                           | R |     |         | NT |     |            |
|                           | A |     |         |    |     |            |
|                           | D |     |         |    |     |            |
|                           | E |     |         |    |     |            |
|                           | / |     |         |    |     |            |
|                           | S |     |         |    |     |            |
|                           | T |     |         |    |     |            |
|                           | E |     |         |    |     |            |
|                           | P |     |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
+---------------------------+---+-----+---------+----+-----+------------+
| TOTAL AMOUNT OF STUDENT   |   |     | STUDENT |    |     |            |
| LOAN REPAYMENT BENEFIT    |   |     | LOAN    |    |     |            |
|                           |   |     | RE      |    |     |            |
| RECEIVED TO DATE          |   |     | PAYMENT |    |     |            |
| *(Include the Requested   |   |     | BENEFIT |    |     |            |
| Amount)*                  |   |     | AMOUNT  |    |     |            |
|                           |   |     | RE      |    |     |            |
| > \$ [     ]{.underline}  |   |     | QUESTED |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     | > \$    |    |     |            |
|                           |   |     | > [     |    |     |            |
|                           |   |     |  ]{.und |    |     |            |
|                           |   |     | erline} |    |     |            |
+---------------------------+---+-----+---------+----+-----+------------+
| STUDENT LOAN REPAYMENT    |   |     | CURRENT |    |     |            |
| BENEFIT FOR YEAR NUMBER   |   |     | BALANCE |    |     |            |
|                           |   |     | OF      |    |     |            |
| *(Check One)*             |   |     | OUTS    |    |     |            |
|                           |   |     | TANDING |    |     |            |
| > 1 2 3 4 5 6 Other       |   |     | LOAN    |    |     |            |
| > [     ]{.underline}     |   |     |         |    |     |            |
|                           |   |     | > \$    |    |     |            |
| **NOTE:** Service         |   |     | > [     |    |     |            |
| Agreement must be         |   |     |  ]{.und |    |     |            |
| attached to this Request  |   |     | erline} |    |     |            |
| form.                     |   |     |         |    |     |            |
|                           |   |     | **      |    |     |            |
|                           |   |     | NOTE:** |    |     |            |
|                           |   |     | O       |    |     |            |
|                           |   |     | fficial |    |     |            |
|                           |   |     | Docume  |    |     |            |
|                           |   |     | ntation |    |     |            |
|                           |   |     | from    |    |     |            |
|                           |   |     | loan    |    |     |            |
|                           |   |     | holder  |    |     |            |
|                           |   |     | docu    |    |     |            |
|                           |   |     | menting |    |     |            |
|                           |   |     | loan    |    |     |            |
|                           |   |     | balance |    |     |            |
|                           |   |     | and     |    |     |            |
|                           |   |     | type of |    |     |            |
|                           |   |     | loan    |    |     |            |
|                           |   |     | must be |    |     |            |
|                           |   |     | a       |    |     |            |
|                           |   |     | ttached |    |     |            |
|                           |   |     | to this |    |     |            |
|                           |   |     | Request |    |     |            |
|                           |   |     | form.   |    |     |            |
+---------------------------+---+-----+---------+----+-----+------------+
| **COMPENSATION**          |   |     |         |    |     |            |
+---------------------------+---+-----+---------+----+-----+------------+
| > Base/Locality Pay \$    |   |     |         |    |     |            |
| > [     ]{.underline}     |   |     |         |    |     |            |
| >                         |   |     |         |    |     |            |
| > Other Continuing Pay,   |   |     |         |    |     |            |
| > e.g., PSP, retention    |   |     |         |    |     |            |
| > allowance \$            |   |     |         |    |     |            |
| > [     ]{.underline}     |   |     |         |    |     |            |
| >                         |   |     |         |    |     |            |
| > Other Payments, e.g.,   |   |     |         |    |     |            |
| > lump sum payments \$    |   |     |         |    |     |            |
| > [     ]{.underline}     |   |     |         |    |     |            |
| >                         |   |     |         |    |     |            |
| > Student Loan Repayment  |   |     |         |    |     |            |
| > Benefit Amount \$       |   |     |         |    |     |            |
| > [     ]{.underline}     |   |     |         |    |     |            |
| >                         |   |     |         |    |     |            |
| > **TOTAL COMPENSATION**  |   |     |         |    |     |            |
| > \$ [0.00]{.underline}   |   |     |         |    |     |            |
+---------------------------+---+-----+---------+----+-----+------------+
| RECOMMENDING OFFICIAL     |   | TI  |         |    |     | DATE       |
|                           |   | TLE |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
+---------------------------+---+-----+---------+----+-----+------------+
| CERTIFICATION OF FUNDS    |   | TI  |         |    |     | DATE       |
|                           |   | TLE |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
+---------------------------+---+-----+---------+----+-----+------------+
| PERSONNEL OFFICIAL        |   | TI  |         |    |     | DATE       |
|                           |   | TLE |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
+---------------------------+---+-----+---------+----+-----+------------+
| APPROVING OFFICIAL        |   | TI  |         |    |     | DATE       |
|                           |   | TLE |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
+---------------------------+---+-----+---------+----+-----+------------+
| EFFECTIVE DATE            |   |     | EXP     |    |     |            |
|                           |   |     | IRATION |    |     |            |
|                           |   |     | DATE    |    |     |            |
|                           |   |     |         |    |     |            |
|                           |   |     |         |    |     |            |
+---------------------------+---+-----+---------+----+-----+------------+

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

PROGRAM SUPPORT CENTER

### REIMBURSEMENT FOR PROFESSIONAL LIABILITY INSURANCE

**(PROGRAM SUPPORT CENTER (PSC) AND\
PSC-SERVICED HHS COMPONENTS)**

**PURPOSE**

Section 636 of the Treasury Postal Service, and General Government
Appropriations Act, 1997, as amended by Public Law\
106-58, Section 642, effective October 1, 1999, requires agencies to use
funds appropriated for salaries and expenses to\
pay an amount not to exceed one-half the costs for eligible employees
who purchase professional liability insurance. This\
instruction sets out the policy and procedures for implementation of
this amended legislation in the PSC and in Department\
of Health and Human Service (HHS) Operating Divisions (OPDIVs) and Staff
Divisions (STAFFDIVs) that are serviced by the\
PSC, Human Resources (HRS). PSC-serviced activities may develop
supplements to this plan, bus such supplementation\
must be coordinated with PSC.

**BACKGROUND**

In 1996, Congress enacted Public Law 104-208 which amend 5 U.S.C. Part
III, Subpart D, Ch. 59, Subchapter 4, Historical\
and Statutory Notes, and authorized agencies to pay not more than
one-half of the cost of professional liability insurance for\
supervisors, management officials, and law enforcement officers.
Professional liability insurance, which can be purchased\
from private organizations by such individuals, generally covers the
cost of a legal defense and damages arising from\
lawsuits against a Federal employee based on the employee's errors or
omissions in the performance of his or her job. In the\
Treasury Appropriation Act for Fy 2000 cited above, the discretionary
agency reimbursement authority was made mandatory.

In the majority of situations, the U.S. Department of Justice will
defend management officials and supervisors (without\
charge) when a wrongful act or omission is alleged to have been
committed while they are acting within the scope of their\
Federal employment. It is unlikely that there will be many incidents, if
any, where individual supervisors actually need\
professional liability insurance. However, if managers and supervisors
desire this insurance and purchase it, such officials\
now will be reimbursed for not more than one-half the cost. In
accordance with the statute, the beneficiaries of this agency\
reimbursement obligation are limited to supervisors, management
officials and law enforcement officers.

**POLICY**

Eligible employees who purchase professional liability insurance to
cover their work activities, upon submission of required\
evidence of such purchase, will be reimbursed one-half of the cost of
professional liability insurance.

**DEFINITIONS**

1\. **Professional Liability Insurance** means insurance that provides
coveragee for:

a.  **Legal liability for damages** due to injuries to other persons,
    damage to their property, or other damage or\
    loss to such other persons (including the expenses of litigation and
    settlement) resulting from or arising out\
    of any tortious act, error, or omission of the covered individual
    (whether common law, statutory or\
    constitutional) while in the performance of such individual's
    official duties as a qualified \[eligible\] employee;\
    and

> b\. **The cost of legal representation** for the covered individual in
> connection with any administrative or judicial\
> proceeding (including any investigation or disciplinary proceeding)
> relating to any act, error, or omission of\
> the covered individual's official duties as a qualified \[eligible\]
> employee, and other legal costs and fees\
> relating to any such administrative or judicial proceeding.

2\. **Supervisors and Management Officials** have the respective
meanings given them by Section 7103(a) of Title 5.\
This section defines the terms as follows:

> a\. **Supervisors** are \". . . individuals employed by an agency
> having authority in the interest of the agency to\
> hire, direct, assign, promote, reward, transfer, furlough, layoff,
> recall, suspend, discipline, or remove\
> employees, to adjust their grievances, or to effectively recommend
> such action, if the exercise of the\
> authority is not merely routine or clerical in nature but requires the
> consistent exercise of independent\
> judgment, except that, with respect to any unit which includes
> firefighters or nurses, the term \"supervisor\"\
> includes only those individuals who devote a preponderance of their
> employment time to exercising such\
> authority.\"
>
> b\. **Management Officials** are \". . . individuals employed by the
> agency in positions the duties and respon-sibilities of which require
> or authorize the individuals to formulate, determine, or influence the
> policies of the\
> agency.\"

**DEFINITIONS** *(continued*)

3\. **Law Enforcement Officers** are employees, the duties of whose
positions are primarily the investigation,\
apprehension, prosecution, or detention of individuals suspected or
convicted of offenses against the criminal laws of the Unites States.

4\. **Eligible Employees** are employees who meet the definitions in
paragraphs 2 and 3 above.

**PROCEDURES FOR OBTAINING REIMBURSEMENT FOR PROFESSIONAL LIABILITY
INSURANCE**

Eligible employees wishing to apply for reimbursement of one-half the
cost of professional liability insurance must submit\
Standard Form 1164, Claim for Reimbursement for Expenditures on Official
Business, approved by a designated\
management official of the employee's agency. Along with this form the
employee must submit a copy of: (1) the insurance\
bill in the employee's name indicating that it is for professional
liability insurance, the period of this policy, and the full amount\
of the policy; and (2) a paid receipt for the full cost of the insurance
(if a check is used as the paid receipt, a copy of both\
sides of the cancelled check is required).

The SF-1164 with documentation must be forwarded through normal
administrative channels and through PSC/HRS for\
verification of employee eligibility prior to signature by the
Certifying Official to whom the OPDIV/STAFFDIV has delegated\
authority to approve these reimbursements.

The original of the certified SF-1164 will be forwarded to the General
Accounting Branch, Financial Management Service,\
PSC, for payment. A copy of the certified SF-1164 and attachments must
be forwarded to PSC/HRS/DPO, Room 17-27,\
Parklawn Building, Rockville, Maryland 20857.