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HR134

ACKNOWLEDGEMENT
OF DEBT

NOTE:
 Forms must be downloaded from the UCT website: http://forms.uct.ac.za/forms.htm
 This form is used by employees when they acknowledge debt to the University due to overpayment and
are unable to repay UCT immediately and in full.
PERSONAL DETAILS
Full Name

Staff Number

Position

Payclass

Department

Tel. No. / Ext

APPLICATION FOR DEBT REPAYMENT PLAN
Date you became aware you had been overpaid
Why was UCT not immediately informed that the
overpayment was in your bank account?

Reasons why you are not able to immediately
repay the money in full

Applicant Signature

Date

FUND TO BE CHARGED IF DEBT AMOUNT NOT SETTLED IN FULL (Completed by Line Manager)
The outstanding debt amount will be charged to the fund below should the staff member default on the agreed repayment
plan.
Fund

Fund Center

Cost Center

REASON FOR OVERPAYMENT (Completed by HR Client Services Manager)

AUTHORITY
Name

Signature

Date

Line Manager/Head of Department
Area Finan