
EMPLOYEE ADVANCE FORM
EMPLOYEE DETAILS (Fill out all fields)
Name:
First Middle Last Last 4 Digits of SSN:
Date of Advance: Company Name: Client No.:
Employee Signature Date
Supervisor/Manager Date
Human Resources Manager/Director Date
Payroll Entry Date
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 ____ emergency payroll
advances per calendar year and that the amount requested shall not exceed ____% 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
□ Other: __________________________________________________________________
By signing this form, I authorize ________________ 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
______________ to deduct any unpaid advance amount from any wages/salary owed me at the time of termination
of employment.