807 A3 Sample Active Employee Repayment Agreement

Georgia State Seal

Georgia Department of Human Services
Human Resources Policy #807 A3

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.

_________________________________
Employee Signature

___________
Date

_________________________________
OHR Director or Designee Signature

___________
Date

_________________________________
OFS Director or Designee Signature

___________
Date