Authorization for Repayment of Advance for Vacation Pay
I, ______________________________, have requested to borrow vacation time of _____
day/days ( from _____________to ____________), which is more than the number
of vacation day/days, which I have earned to date. In order to use this vacation time, I
request that the City advance vacation time to me for ________ hours times my current
hourly rate of pay __________, which amounts to ____________.
In the event that my employment is terminated or I resign prior to earning enough
vacation time to cover this advance, I agree to;
A. Repay any remaining unearned balance at the time I cease to be employed by the
City; and to;
B. Allow the City to deduct any amount, which I owe from my last paycheck, and/or any
future pay out, which may be due to me after the termination of my employment.
Dated: _____________________________
Signature: _______________________________________
Print Name: _______________________________________
Department Head: ________________________________________
Human Resources Director: _______________________________________
Do you have any Floating Holidays or Compensatory time that can be used for this event.
If so how much? ______________ Hours.
These should be used prior to requesting advanced vacation time.
Please return this form to the Personnel Department as soon as possible.
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