Form E-64 - Payroll Advance Request And Deduction Form printable pdf download

Form E-64 - Payroll Advance Request And Deduction Form

ACCESSIBLE HEALTHCARE SOLUTIONS

PAYROLL ADVANCE REQUEST

AND DEDUCTION FORM

Form E-64

Employee Name Printed

Employee Social Security Number

I request a payroll advance of $_______________. I understand that I will be charged an administrative

fee of $_____________ to process this request.

I authorize a payroll deduction of $_______________________ to be taken from my paycheck on

_____________________. If sufficient wages, net of all mandatory deductions, is not available to repay

the advance and administrative fee on that date, the maximum amount possible will be deducted for

repayment and will continue to be deducted from subsequent paychecks until the advance is repaid. In

the event that I should terminate employment with Accessible Healthcare Solutions prior to repayment of

the entire advance, I fully understand that any unpaid balance will then become immediately due and

payable to Accessible Healthcare Solutions.

Employee Signature

Date Signed

Employee Direct Supervisor

Employee Work Location

DO NOT WRITE BELOW THIS LINE – FOR PAYROLL USE ONLY

Hire date:

Write Ups:

Weekly Hours:

Weekly Wages:

Notes:

Approved Amount:

Signature (Payroll Representative)/Date

This form must be signed by the employee and the person authorizing the advance.

Date disbursed:

Check Number:

Date Paid in Full: _________________

Form E-64 - Payroll Advance Request And Deduction Form