Employers Group
[pic]
Final Paycheck Acknowledgement
I, the undersigned recipient, have received my final paycheck from __(Company Name)__.
The total amount of the paycheck is: __($)__
Paycheck amount represents:
Wages __($)__
Accrued Vacation Pay __($)__
Bonus __($)__
Commission __($)__
Other __($)__
__($)__
__($)__
Deductions
_____________________________ __($)__
_____________________________ __($)__
_____________________________ __($)__
To the best of my knowledge, there is no additional money owed to me by the employer at the present time.
___________________________________ _____________________
Name of Recipient (please print) Dept.
________________________________________ _____________________
Signature of Recipient Date
_______________________________________ _____________________
Signature of Person Issuing Final Paycheck Date
................
................
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