FILLING OUT THIS FORM DOES NOT GUARANTEE THAT AND ADVANCE WILL BE APPROVED. MANAGER MUST RECEIVE AND APPROVE ALL REQUESTS.

First Name (required)

Last Name (required)

Request Date (required)

I am requesting from Service Solutions Center either an employee loan or payroll advance in the amount of

By checking this box, I understand and agree that I will repay the amount in full using funds via my payroll. Should my employment be terminated for any reason, prior to the complete repayment, the remaining balance due will be deducted from my final paycheck.

If the final paycheck is insufficient to cover the complete re-payment of this loan, then I will continue to make bi-monthly payments until the balance is paid in full. Service Solutions Center has the right to incur interest on the outstanding balance as well as collecting these funds at my expense (including attorney fees) should I default on the terms of this loan.

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I Agree to the above statement

Please Type your Initials to Confirm Everything in this request (required)