V030707 Final Paycheck Acknowledgment

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Final Paycheck Acknowledgment

v030707

I, the undersigned recipient, have received my final paycheck from:

______________________________

Company

The total amount of the paycheck is: $ __________

Paycheck amount represents: Wages

Accrued Vacation Pay

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

________________________________________________________

Signature of Recipient

__________

Date

________________________________________________________

Signature of Person Issuing Final Paycheck

__________

Date

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