REQUEST FOR PAYROLL ADVANCE
Complete this form to request an advance of wages earned.
The Oregon Accounting Manual (OAM) policy 42.25.00.PO or the applicable
collective bargaining agreement governs payroll advances. They are for emergency
situations only.
Section 1: Completed by Employee
NAME OF EMPLOYEE
Employee ID Number (EIN)
*
OR
WORK LOCATION (COST CENTER,NAME, #)
PHONE NUMBER
AMOUNT OF REQUEST
(Not to exceed 60% of gross wages
earned to date this pay period.)
*
Management or Executive Service
Unrepresented
Represented by ____________________________
* Reason: (Must comply with applicable collective bargaining agreement or DAS administrative rules.)
Death in family necessitating unforeseen
expenditures or travel.
Major car repair such as engine, transmission or
catastrophic failure.
Theft of cash representing major portion of most
recent pay.
Automobile accident leading to loss of vehicle use.
Accident or sickness (self or family) requiring
immediate substantial cash outlays.
Destruction or major damage to home requiring
immediate substantial cash outlays.
New employee lack of funds (maximum – 1 draw).
Unreimbursed moving expenses due to transfer or
promotion. This does not include personal moving
situations such as purchasing a home or renting a
different residence.
Other:____________________________________-
_____________________________________________
Refer to appropriate collective bargaining agreement and statewide/agency policies
for documentation requirements.
For the consideration of ($_________), I hereby assign and transfer to _______________________ such amount
(Amount Requesting) (State Agency)
of my salary due me for the State of Oregon for the month ending _________________, and hereby authorize the
(Pay Period End Date)
said assignee to with