Connecticut Department of Labor, Partner of the American Job Center Network
  Home About Us FAQ News and Notices Contact Us
Unemployment Benefits On-Line Job Seekers Employers Labor Market Information Directions/Office Information

 

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 YOUR USE. 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.


(use the Tab key to move forward a field and Shift-Tab to move back a field)
Company Name:
Street Address:
City:
State:    Zip Code: 
Person Requesting Form
Telephone Number:
E-Mail Address:

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):  _________________________________________


200 Folly Brook Boulevard, Wethersfield, CT 06109 / Phone: 860-263-6000

Home | 
CT.gov Home Send Feedback<%end if%><%if cbool (request.Cookies(Application("HOME_NAME"))("AA"))=true and request.Cookies(Application("HOME_NAME"))("CA")<>"CF83CBC7" then call Session_WriteString(" | Admin") end if%>
State of Connecticut Disclaimer and Privacy Policy. Copyright 2002 - 2011 State of Connecticut