Authorization for Repayment of Advance for Vacation Pay or Paid Time Off

Authorization for Repayment of Advance for Vacation Pay or Paid Time Off
PLEASE COMPLETE THE FORM BELOW AND YOU WILL BE CONSIDERED FOR APPROVAL OF ADVANCE FOR VACATION PAY OR PAID TIME OFF (PTO) PAY, CONNECTICUT STATUTE 31-71e AND NOTIFIED BY EMAIL/MAIL.

* THERE IS A SAMPLE OF AN AUTHORIZATION FOR PAYROLL DEDUCTION FORM FOR APPROVAL OF ADVANCE FOR VACATION PAY OR PAID TIME OFF (PTO) PAY, CONNECTICUT STATUTE 31-71e AVAILABLE BELOW. PLEASE NOTE THIS IS JUST A SAMPLE Of WHAT YOU WILL RECEIVE IN THE MAIL AND IS NOT TO BE COMPLETED.
Company Name:*
Company Name
Street Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Person Requesting Form:*

First NameLast Name
Telephone Number:*
Please enter a valid phone number.
Email Address:*
example@example.com
WOULD YOU LIKE TO VIEW A SAMPLE OF AUTHORIZATION FOR REPAYMENT OF ADVANCE FOR VACATION PAY OR PAID TIME OFF (PTO) PAY, CONNECTICUT STATUTE 31-71e THAT YOU WILL BE RECEIVING IN THE MAIL? SELECT YES BELOW TO SEE SAMPLE; SELECT NO TO SUBMIT FORM*

YesNo
PLEASE NOTE THIS IS JUST A SAMPLE OF THE FORM YOU WILL RECEIVE IN THE MAIL AND IS NOT TO BE COMPLETED.
I have requested to take paid vacation time or PTO time for a number of days/hours which is more than the number of paid vacation or PTO time which I have earned to date. I request that the company advance vacation pay or PTO pay to me in the amount of
$ ____________________.

In the event that my employment is terminated or I resign prior to earning enough time to cover this advance, I agree to:

(A)   Repay any remaining unearned balance at the time I cease to be employed by the company; and to
(B)   Allow the company to deduct any amount which I owe from my last paycheck and/or any future commission checks which may be due to me after the termination of my employment.

Dated: _________

Signature (employee):   _________________________________________
Should be Empty: