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Form Dma-7060 - Voluntary Repayment Agreement - North Carolina Department Of Social Services

VOLUNTARY REPAYMENT AGREEMENT

County of

Department of Social Services

I, _____________________, case number _____________, without being coerced, freely admit and fully

understand that I have received public assistance/medical assistance/food stamps in the amount of

$____________ to which I was not entitled.

[ ]

I agree to repay $____________ each week/month until the full amount of $____________ is

repaid. Effectively date of the first payment is ___________ and the full amount should be repaid by

______________. If I fail to make regular payments and I am then receiving assistance, I understand my

benefits will be reduced.

[ ]

I agree to repay $____________ each month by WFFA check deductions/FNS allotment

reduction until the full amount of $___________ is repaid. Should my income fluctuate, it could result in

an allotment reduction change. I understand that amount taken then will be 10% of $10.00 whichever is

greater. Effective date of the first payment is _____________________ and this amount should be repaid

by __________________. If benefits are terminated, I agree to repay the remaining balance by cash.

[ ]

I understand that the amount of Medical Assistance overpayment is subject to change due to all

providers having 12 months from date of service to file claim for payment, and that, therefore, all claims

may not have been paid yet. I agree to pay for any additional amount that may be added due to this

reason. I understand I will be notified of any additional amounts.

Do not send cash through the mail. We will only accept a cashier's check, certified check, or money order.

When paving in cash, bring in only correct change. Cash payments can be made to:

SEAL

Client Signature

Date:

Worker Signature

North Carolina

________________ County

I, _______________________, A Notary Public for said County and State, do hereby certify that

____________________________ personally appeared before me this date and acknowledged the due

execution of the foregoing instrument.

Witnessed my hand and official seal, this the _____ day of ___________, ____.

OFFICIAL

SEAL

Notary Public

My commission expires:

, ____

Issued 10/2011

DMA-7060

Form Dma-7060 - Voluntary Repayment Agreement - North Carolina Department Of Social Services