Employment Benefits Charge-Back

The undersigned officer or employee of __________________, (the "Company"), agrees to repay to the Company all benefits, compensation payments or reimbursements which may be disallowed, in whole or in part, as a deductible expense.  The reimbursement shall be made to the full extent of the disallowance upon an adverse decision of the last agency to consider the issue, provided that the Company shall not be obligated to seek further appeal, if available, unless it so chooses.


Signed this _________day of______________, 201(x) .




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