Form Doj-Jmd-Fs-2 Investigation Report Form Page 4
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4Employee Name: ________________________________
Do any of the following denial standards apply? If yes, indicate item number(s): ____________
1.
There was indication of fraud, misrepresentation, fault, or lack of good faith (derived from
an act or a failure to act).
2.
Employee received or had access via the Internet comprehensible Earnings & Leave
Statements and/or T&A Reports, yet was paid for more hours in a pay status than his/her
entitlement.
3.
Employee’s job occupation was in the area of personnel or payroll, which precluded
him/her from claiming no knowledge of the pay error.
4.
Employee was not new to the Federal government (as reflected in his/her Federal Service
Comp Date), and the error was not of a complex nature.
5.
Employee received a letter, memo, or notice outlining his/her pay setting, pay cap, or pay
entitlements.
6.
Employee signed an agreement for an allowance, but did not fulfill the terms of such
agreement.
7.
Employee signed an election form for a benefit that was not sufficiently deducted from
his/her pay.
8.
Employee’s leave adjustment(s) did not result in a negative leave balance at any time.
Therefore, there is no claim to waive.
Personnel Officer’s Recommendation & Reason(s) (include amount(s) recommended to be approved
and/or denied):
Amount Recommended to be Approved:
$_________________
Amount Recommended to be Denied:
$_________________
_____________________________________________________________________________________
_______________________________
____________________
(Signature of Personnel Officer)
(Date)
DECISION:
Amount Approved:
$__________________
Amount Denied:
$__________________
Decision Official’s Reason for Disagreement or Concurrence if Different Reason than Agency’s:
______________________________________________________________________________
________________________________
_____________________
Decision Official’s Signature
(Date)
Decision Official’s Title: __________________________________________
U.S. DOJ - Inv Rep Form
Form DOJ-JMD-FS-2 (06-16-03)
Authorized for Local Reproduction
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