WAGE ADVANCE REQUEST

Employee Name: Last 4 Digits of Soc. Sec. No.:

Company Name: Date of Advance:

I, _____________________________________________, request an advance payment

[employee name]
of $_____________________ on my wage/salary to be paid on __________________________.
[amount of advance] [payment date]

If this request is approved, I would like to receive this advance by (select one):
___ check ___ direct deposit

I agree to the following repayment term (select one):

___ I agree that this salary advance will be repaid in full through one lump-sum payroll
deduction from my next scheduled paycheck.
___ I agree that this salary advance will be repaid through equal deductions from my next
______[number] paychecks.
If employment is terminated either by me or the company before the advance is fully repaid, I
authorize the company to deduct any unpaid balance due from my final paycheck.

Employee signature:___________________________ Date:________________

Approved by:
Print Name & Title: ____________________________________________________
Signature:___________________________________ Date:________________