Appendix A: Repayment Agreement and Decline of Service Form

Click here for the repayment agreement.

Payments should be made by check or money order payable to “DHHS/PSC/HHS/Repatriate”. Payment should be mailed to:

Department of Health and Human Services
Program Support Center (PSC-HHS)
Attention: Repatriation Collections Officer
5600 Fishers Lane
Room 8-B45
Rockville, Maryland 20857

Distribution: Original to FSA Administrator, Copy to Repatriate, Copy retained by State Agency.

Click here for the decline of service form.

Reissued June 24, 2009, replacing May 16, 2008; reviewed March 16, 2012