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If this request is approved, I would like to receive this advance by physical check / direct deposit (circle one). By signing this form, I authorize Employer Flexible to make deductions from my paycheck to repay this advance through either: 1) one payroll deduction to be made from wages/salary payable the first pay period 

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Jul 25, 2008 If you ever want to be repaid for a salary advance, use this or a similar form to get a very clear statement from the employee about your rights to make (Employee) request an advance payment of $______ (amount) on my wages that I otherwise would receive on the payroll date of ______ ___, 20__.