807 A3 Sample Active Employee Repayment Agreement
Georgia Department of Human Services |
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Sample Active Employee Repayment Agreement |
Date
This agreement is entered into with the Department of Human Services and the employee listed below.
I, ________________, acknowledge and do not dispute, the debt owed to the Department of Human Services in the amount of $ ____________. I agree to the following installment repayment schedule as set forth below. The first payment to be deducted from my regular earnings on _________, with the final payment of $ _______, from my regular earnings on ___________.
Payment Due Date |
Amount Due |
Date Received (OFS Use Only) |
I understand that if I resign or my employment with the Department of Human Services is terminated before completing this repayment agreement, my final regular earnings paycheck and/or accrued annual leave paycheck will be applied to this debt, and I will remain responsible for any additional amount owed following such application.
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Employee Signature
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Date
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OHR Director or Designee Signature
___________
Date
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OFS Director or Designee Signature
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Date