Salary/Wage Advance Form

Employee Name: ______________________                     Date: ____________

I, [Employee Name], request an advance payment of [amount] on my wages/salary to be paid on [date] due to [reason for request] as permitted by company policy.

I agree to repay this advance as follows (select one):

____ One lump-sum payroll deduction to be made from my wages/salary on the first pay period immediately following the pay period from which this advance is made.

____ By [number] equal deductions from the next [number] paychecks immediately following the pay period from which this advance is made.

I also agree that if I terminate employment prior to total repayment of this advance, I authorize the company to deduct any unpaid advance amount from the wages/salary owed me at the time of termination of employment.

Employee signature: ________________________             Date: ____________

Approved by:

Supervisor signature: ________________________            Date: _____________

Human resources signature: ___________________           Date: _____________