University of Michigan Repayment Agreement

I, (Employee ID: )

acknowledge a debt of $ ______owed to the University of Michigan.

This debt is the result of:

Repayment

 Set up deductions as allowable by law, 15% of gross, until overpayment is paid in full

 Set up ______deductions of $______each until overpayment is paid in full

(If greater than 15% of gross)

Repayment Schedule

Repayment of this overpayment will be made in accordance with the following schedule. Payroll deductions will be made from every payroll between and including each of the following Pay Dates.

Repayment Starting Pay Date _____ Repayment Final Pay Date ______

Authorization

I authorize all payroll deductions as specified above. Furthermore, should my employment at the University of Michigan end prior to the completion of the Repayment Schedule, I authorize a maximum payroll deduction allowed by law to be withheld from my final paycheck. I also agree to repay the University of Michigan within six months of the end of my employment, the remaining balance of the debt that has not been repaid via payroll deduction.

Signature Date

Approval - Departmental Representative Date

Fax: (61)5-5822

Business Unit

Inpatient Nursing I Emergency Medicine, Physical Medicine & Rehab, Speech Language, & Survival Flight

Ambulatory Care and Center I Medical School Administration Pathology and Psychiatry Surgical Services

Internal Medicine I Internal Medicine II Business Services I Business Services II Support Services

Inpatient Nursing II CCOPS Homecare, Pharmacy & Respiratory Care Cardiovascular Center, Neurology, Radiation Oncology and ULAM Ambulatory Care and Center II Radiology, Orthopaedic & Urology

Anesthesiology, Otolaryngology, & Dermatology Pediatrics and Women’s Administrative Services OR and Surgical Centers Cancer Center and Medical School and Basic Sciences

NOTE: Departments are allowed flexibility to select repayment preferences however; the UMHS Payroll Office may secure review by the Office of the General Counsel, when they deem it necessary

Updated by UMHS Payroll 03/16/2017