of Responsibility for Repayment of Monies Owed
Why do I need to fill out this form?
You need to sign this form in case you are overpaid
and leave your job in the future before making repayment.
The form gives the department permission to
some of your final pay if necessary.
* .PDF refers to Portable Document Format, which is a readable
format for many types of web documents. If you do not have
Adobe Acrobat Reader installed on your computer, you will
not be able to see the form. Acrobat Reader is free and available
at the Adobe website:
Adobe Acrobat Reader
Click here to return to the Forms