Form E-64 - Payroll Advance Request And Deduction Form

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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: _________________

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