807 A4 Sample Inactive Employee Repayment Agreement

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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 of $ _________, due on __________ and the final payment of $ __________ due on _____________.

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Employee Signature

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OHR Director or Designee Signature

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OFS Director or Designee Signature

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