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REPAYMENT AGREEMENT
ACKNOWLEDGEMENT OF DEBT
(REPAYABLE)
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Employment and Assistance Act or the
Employment and Assistance for Person with Disabilities Act. The collection, use and disclosure of personal information is subject to the provisions of the Freedom of Information and
Protection of Privacy Act. Any questions about this information should be directed to your Employment and Assistance Centre.

FOR PLMS USE ONLY

OFFICE CODE

DATE (YYYY MMM DD)

FILE ID:

(CLOSED FILE)

I/We acknowledge that I/we received $
of assistance which
is repayable under the Employment and Assistance Act or the Employment and Assistance
for Persons with Disabilities Act. I/We further acknowledgement that such payment
constitutes a debt to the Province in the same amount.
I/We jointly and separately agree to pay Her Majesty the Queen in right of the Province of
British Colu