Authorization For Repayment Of Advance
For Vacation Pay OR PAID TIME OFF
THIS IS A SAMPLE OF AN AUTHORIZATION FOR
REPAYMENT OF ADVANCE FOR VACATION PAY OR PAID TIME OFF (PTO) PAY, CONNECTICUT STATUTE 31-71e FOR
THIS IS JUST A SAMPLE AND IS NOT TO BE COMPLETED.
IF YOU WISH TO USE IT TO AUTHORIZE REPAYMENT OF ADVANCE FOR VACATION PAY OR PAID
TIME OFF (PTO) PAY, PLEASE
COMPLETE THE ITEMS BELOW AND YOUR COMPANY WILL BE CONSIDERED FOR APPROVAL AND
NOTIFIED BY MAIL.
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.
Signature (employee): _________________________________________