EMPLOYEE ADVANCE AGREEMENT - Employer Flexible
[Pages:1]EMPLOYEE ADVANCE AGREEMENT
EMPLOYEE INFORMATION (Complete all fields.)
Employee Name:
First
Middle
Last
Date of Advance:
Client Company Name:
Last 4 Digits of Soc. Sec. No.: Client No.:
I,
, request an advance payment of $
on my wages/salary
payable on the payroll date of
. I understand that I am eligible for no more than two
emergency payroll advances per calendar year and that the amount requested shall not exceed 60% of my
earnings to date for the current month. If this request is approved, I would like to receive this advance by
physical check / direct deposit (circle one).
By signing this form, I authorize Employer Flexible to make deductions from my paycheck to repay this advance through either: 1) one payroll deduction to be made from wages/salary payable the first pay period immediately following the pay period from which this advance is made or: 2) from equal deductions from the next pay periods 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 Employer Flexible to deduct any unpaid advance amount from any wages/salary owed me at the time of termination of employment.
Approved by:
Employee Signature
Date
Supervisor/Manager
Date
Human Resources Manager/Director
Date
Payroll Entry
Date
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