Ps Form 3074 – Fill Out and Use This PDF

Request for Waiver of Claim for

Erroneous Payment of Pay

PART I. To Be Completed by Claimant

1. Claimant’s Name (Last, First, MI)	2. Employee Identification Number (EIN)		3. Claimant’s Status:
			Active Employee
			Former Employee
4. Claimant’s HomeAddress (Street, City, State, ZIPCode™; include apt no.		5. Name and Location of Organization to WhichAssigned
If applicable)

6. Period Covered by Erroneous Payment of Pay (MM/DD/YYYY)

From:

To:

7.Amount Requested for Waiver: $

8. P.O. Invoice Number:

Date:

(Attach copy)

9. Describe the nature of the erroneous payment for pay. (Attach separate sheet if necessary.)

10.Did you ask your supervisor about the possible error in your pay? If so, furnish details.

11.State the circumstances you feel justify waiver of this claim.

12. If you have made any repayments, list amounts and dates repaid.

PrivacyAct Statement:Your information will be used to consider a waiver of claims for erroneous payment of pay. Collection is authorized by 39 U.S.C. 401, 409, 410, 1001, 1003, 1004, 1005, 1206; and 29 U.S.C. 2601 et seq.

Providing the information is voluntary, but if not provided, we may be unable to process your request. We may disclose your information as follows: in relevant legal proceedings; to law enforcement when the U.S. Postal Service (USPS) or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel; the Selective Service System, records pertaining to supervisors and postmasters may be disclosed to supervisory and other managerial organizations recognized by USPS; and to financial entities regarding financial transaction issues.

PS Form 3074,September 2010 (Page 1 of 2) PSN 7530-03-000-3700

1 — EaganAccounting Services

PART II. To Be Completed by Current Postmaster or Installation Head of theActive or Former Employee

(Retain one copy. Forward original and one copy to Manager, Human Resources (District).

Provide all additional facts or circumstances that will clairfy and amplify the statement of facts made by the claimant on the claim form, including a descritpion of how the overpayment occurred. (Continue on separate sheet, if necessary)

GrossAmount of Claim Listed by Pay Periods

Pay		Amount	Pay		Amount	Pay		Amount
Period	Amount Paid	Should Be	Period	Amount Paid	Should Be	Period	Amount Paid	Should Be
$	$		$	$			$	$
$	$		$	$			$	$
$	$		$	$			$	$

To the best of my knowledge and belief there is no indication of fraud, misrepresentation fault, or lack of good faith on the part of the claimant or any other person having an interest in this request for waiver of claim.

Signature	Title	Date (MM/DD/YYYY)
Printed Name	Phone Number

PART III. To Be Completed by Manager, Human Resources (District).

(Retain one copy. Forward original to EaganAccounting Services.)

Review form for accuracy and completeness.Add any additional pertinent facts. (Continue on separate sheet, if necessary.)

Signature	Title	Date (MM/DD/YYYY)
Printed Name	Phone Number

PART IV. To Be Completed by Manager, EaganAccounting Services.

GrossAmount Claimed	$	ClaimAllowed
GrossAmount Waived	$	ClaimDenied
Signature	Title		Date (MM/DD/YYYY)

MAIL TO:ACCOUNTING SERVICES, 2825 LONE OAK PKWY, EAGAN MN 55121-9616

PS Form 3074,September 2010 (Page 2 of 2) PSN 7530-03-000-3700

Request for Waiver of Claim for

Erroneous Payment of Pay

PART I. To Be Completed by Claimant

1. Claimant’s Name (Last, First, MI)	2. Employee Identification Number (EIN)		3. Claimant’s Status:
			Active Employee
			Former Employee
4. Claimant’s HomeAddress (Street, City, State, ZIPCode™; include apt no.		5. Name and Location of Organization to WhichAssigned
If applicable)

6. Period Covered by Erroneous Payment of Pay (MM/DD/YYYY)

From:

To:

7.Amount Requested for Waiver: $

8. P.O. Invoice Number:

Date:

(Attach copy)

9. Describe the nature of the erroneous payment for pay. (Attach separate sheet if necessary.)

10.Did you ask your supervisor about the possible error in your pay? If so, furnish details.

11.State the circumstances you feel justify waiver of this claim.

12. If you have made any repayments, list amounts and dates repaid.

PrivacyAct Statement:Your information will be used to consider a waiver of claims for erroneous payment of pay. Collection is authorized by 39 U.S.C. 401, 409, 410, 1001, 1003, 1004, 1005, 1206; and 29 U.S.C. 2601 et seq.

Providing the information is voluntary, but if not provided, we may be unable to process your request. We may disclose your information as follows: in relevant legal proceedings; to law enforcement when the U.S. Postal Service (USPS) or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel; the Selective Service System, records pertaining to supervisors and postmasters may be disclosed to supervisory and other managerial organizations recognized by USPS; and to financial entities regarding financial transaction issues.

PS Form 3074,September 2010 (Page 1 of 2) PSN 7530-03-000-3700

2 — Manager, Human Resources

PART II. To Be Completed by Current Postmaster or Installation Head of theActive or Former Employee

(Retain one copy. Forward original and one copy to Manager, Human Resources (District).

Provide all additional facts or circumstances that will clairfy and amplify the statement of facts made by the claimant on the claim form, including a descritpion of how the overpayment occurred. (Continue on separate sheet, if necessary)

GrossAmount of Claim Listed by Pay Periods

Pay		Amount	Pay		Amount	Pay		Amount
Period	Amount Paid	Should Be	Period	Amount Paid	Should Be	Period	Amount Paid	Should Be
$	$		$	$			$	$
$	$		$	$			$	$
$	$		$	$			$	$

To the best of my knowledge and belief there is no indication of fraud, misrepresentation fault, or lack of good faith on the part of the claimant or any other person having an interest in this request for waiver of claim.

Signature	Title	Date (MM/DD/YYYY)
Printed Name	Phone Number

PART III. To Be Completed by Manager, Human Resources (District).

(Retain one copy. Forward original to EaganAccounting Services.)

Review form for accuracy and completeness.Add any additional pertinent facts. (Continue on separate sheet, if necessary.)

Signature	Title	Date (MM/DD/YYYY)
Printed Name	Phone Number

PART IV. To Be Completed by Manager, EaganAccounting Services.

GrossAmount Claimed	$	ClaimAllowed
GrossAmount Waived	$	ClaimDenied
Signature	Title		Date (MM/DD/YYYY)

MAIL TO:ACCOUNTING SERVICES, 2825 LONE OAK PKWY, EAGAN MN 55121-9616

PS Form 3074,September 2010 (Page 2 of 2) PSN 7530-03-000-3700

Request for Waiver of Claim for

Erroneous Payment of Pay

PART I. To Be Completed by Claimant

1. Claimant’s Name (Last, First, MI)	2. Employee Identification Number (EIN)		3. Claimant’s Status:
			Active Employee
			Former Employee
4. Claimant’s HomeAddress (Street, City, State, ZIPCode™; include apt no.		5. Name and Location of Organization to WhichAssigned
If applicable)

6. Period Covered by Erroneous Payment of Pay (MM/DD/YYYY)

From:

To:

7.Amount Requested for Waiver: $

8. P.O. Invoice Number:

Date:

(Attach copy)

9. Describe the nature of the erroneous payment for pay. (Attach separate sheet if necessary.)

10.Did you ask your supervisor about the possible error in your pay? If so, furnish details.

11.State the circumstances you feel justify waiver of this claim.

12. If you have made any repayments, list amounts and dates repaid.

PrivacyAct Statement:Your information will be used to consider a waiver of claims for erroneous payment of pay. Collection is authorized by 39 U.S.C. 401, 409, 410, 1001, 1003, 1004, 1005, 1206; and 29 U.S.C. 2601 et seq.

Providing the information is voluntary, but if not provided, we may be unable to process your request. We may disclose your information as follows: in relevant legal proceedings; to law enforcement when the U.S. Postal Service (USPS) or requesting agency becomes aware of a vio- lation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform au- dits; to labor organizations as required by law; to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel; the Selective Service System, records pertaining to supervisors and postmasters may be disclosed to supervisory and other managerial organizations recognized by USPS; and to financial entities regarding financial transaction issues.

PS Form 3074,September 2010 (Page 1 of 2) PSN 7530-03-000-3700

3 — Installation Head

PART II. To Be Completed by Current Postmaster or Installation Head of theActive or Former Employee

(Retain one copy. Forward original and one copy to Manager, Human Resources (District).

Provide all additional facts or circumstances that will clairfy and amplify the statement of facts made by the claimant on the claim form, including a descritpion of how the overpayment occurred. (Continue on separate sheet, if necessary)

GrossAmount of Claim Listed by Pay Periods

Pay		Amount	Pay		Amount	Pay		Amount
Period	Amount Paid	Should Be	Period	Amount Paid	Should Be	Period	Amount Paid	Should Be
$	$		$	$			$	$
$	$		$	$			$	$
$	$		$	$			$	$

To the best of my knowledge and belief there is no indication of fraud, misrepresentation fault, or lack of good faith on the part of the claimant or any other person having an interest in this request for waiver of claim.

Signature	Title	Date (MM/DD/YYYY)
Printed Name	Phone Number

PART III. To Be Completed by Manager, Human Resources (District).

(Retain one copy. Forward original to EaganAccounting Services.)

Review form for accuracy and completeness.Add any additional pertinent facts. (Continue on separate sheet, if necessary.)

Signature	Title	Date (MM/DD/YYYY)
Printed Name	Phone Number

PART IV. To Be Completed by Manager, EaganAccounting Services.

GrossAmount Claimed	$	ClaimAllowed
GrossAmount Waived	$	ClaimDenied
Signature	Title		Date (MM/DD/YYYY)

MAIL TO:ACCOUNTING SERVICES, 2825 LONE OAK PKWY, EAGAN MN 55121-9616

PS Form 3074,September 2010 (Page 2 of 2) PSN 7530-03-000-3700