University of Washington
Overpayment Repayment Option Form-Active Employees
Date: 10/10/2008
From: ___________________________________________ Phone: _________________________________
(Payroll Coordinator/Contact Person) E-mail: _________________________________
________________________________ ________ Fax: ____________________________________
(Department) (Payroll Unit Code)
To: Marie Atienza Phone: (206) 616-4362 Fax: (206) 543-8137
Payroll Office Box 355655 e-mail: overpay@u.washington.edu
Re: ____________________________________ EID: ____________________________________
I, ____________________________________, have decided to choose the following option to
repay the salary or wages overpaid to me in the gross amount of $: ______________________________
These options are processed within the next pay cycle if the signed Overpayment forms,
including the backup, are received in the Payroll Office by noon on final cut-off.
_______ 1. I choose to have the total gross amount taken out of my next paycheck.*
_______ 2. I choose to have payroll installment deduction in the amount of________________________
spread over ______________________ pay periods.
Note: the installment plan requires a $50.00 payment minimum or a payment spread
over the maximum of 12 pay periods, WHICHEVER is larger.
________3. I choose to have the total amount of overpaid hours deducted from my vacation and/or
compensatory time balance as of today. (Please attach a copy of OWLS record reflecting
the deduction.)
Note: Before this overpayment is considered paid in full, the Payroll Office must
receive a copy of the OWLS Time & Leave record.
In the event that I terminate employment prior to full repayment through payroll deduction,
I understand that any unpaid balance of the debt will be deducted from my final paycheck.
Overpayment amounts referred to collections may be subject to credit bureau reporting and/or
collection fees and interest.
EMPLOYEE SIGNATURE: __________________________________________________
DATE: _________________________________________________________
*Please note: if you have any questions, please contact your Departmental Payroll Coordinator
directly, as indicated by the “From” line above.