Page 93

COUNTY OF

STATE OF ALABAMA

NAME

S.S.N.:

REPAYMENT AGREEMENT

I,

, understand and acknowledge that I have received payments or benefits under the Low-Income Home Energy Assistance Program (LIHEAP) to which I was not entitled valued at and in the amount of $

from the

Community Action Agency.

I agree and stipulate that I owe the Agency $

and I promise to pay that amount to the Agency in equal installments of $

, and one installment of $

, such payments to begin on

, 20 , and to be made by the

day of each month thereafter, until the full amount is paid.

I agree that if I fail to pay any of the installments under the terms of this agreement I shall be considered to be in default of this agreement and all of the installments comprising the balance of the entire amount due the Agency may become immediately due and payable without notice or demand.

In case of any default in this agreement, I agree to pay any and all costs incurred in any steps taken to collect on the agreement. I further agree to pay the cost of any reasonable fee of any attorney hired to collect on this agreement.

I agree that this repayment agreement supersedes and replaces any repayment agreement here-to-fore signed by me for the above claim or overissuance period.

Done this the day of

, 20

.

Signature

Agency Representative

Witnessed:

LIHEAP-120 Reviewed 2024