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PAY ADVANCE REQUEST FORM SUBMIT TO PAYROLL SUBMIT TO PAYROLL SUBMIT TO PAYROLL This form must be completed legibly by employees who wish to receive a pay advance, which will be issued in the form of a paper check. The form must be submitted no later than noon on Wednesdays between payday and payroll cut off in order to receive a check the following Friday. Please read this pay advance policy summary carefully before completing the form. Pay advances are only issued between payday and the payroll cutoff date to eligible employees. If payday occurs on a Wednesday or Thursday, no pay advances will be issued on the following Friday. Benefitted employees are eligible for three advances per rolling calendar year, and non-benefitted employees are eligible for one advance per rolling calendar year. Up to 75% of the wages earned and unpaid at the pay advance issue date may be requested. EMPLOYEES MUST FULLY COMPLETE THE SECTION BELOW. Incomplete forms will not be processed. Employee Full Name: Date: Phone Number: Home Department: 1. I am requesting a pay advance for this amount: be dollar amount) 2. The amount requested above does not exceed 75% of my earned and unpaid wages to date. Yes No 3. Please specify the Friday date you wish to pick up your pay advance (see possible issue dates in policy at top of form): 4. I understand that this pay advance will be deducted from my next paycheck. Yes No 5. I understand that pay advances are only processed between payday and the payroll cutoff date, and I have delivered this form to the Finance Division in City Hall in accordance with the stated Wednesday deadline. Yes No (Employee Signature) (Date) For Payroll Use Only Employee has worked appropriate hours to receive requested amount: Yes No Employee submitted form in accordance with stated deadlines: Yes No Employee is eligible to receive a pay advance based on the following pay advance history: Yes No Documentation is attached confirming pay advance eligibility amount or work is shown on form: Yes No Previous Pay Advances Date: Date: Date: Check Check Date: Initials: Revised Sept 2016 SIGN