Wage Assignment Form

WAGE ASSIGNMENT FORM

This agreement is hereby made between {Employee} at {Company, Address} (hereafter referred to as "Employee"), and {Recipient} at {Company, Address} (hereafter referred to as "Recipient").

As of {date}, the Employee hereby voluntarily assigns and transfers {monetary amount} from {type of income/wages} to the Recipient every {frequency}. (Or, the Employee hereby voluntarily assigns and transfers {percentage} of {his/her} total wages from {type of income} to the Recipient.

The Employee will transfer funds through {transaction/program type} automatically on the {first/Monday/etc.} of every {month/week/etc.}. The payments will occur until the entire amount of {amount} is paid, and then they will cease automatically.

According to {state or workforce law}, the Employee shall not be obligated to pay more than {amount} per {frequency}.

If the Employee fails to pay the full amount each period, the following penalties shall occur:

{Penalties}

The terms and conditions laid out in this contract constitute the entire agreement. Any additions, waivers, or conditions must be put forth in writing and signed by both parties.

_________________________________________
(Employee's Signature)

_________________________________________
(Recipient's Signature)

_________________________________________
(Date)

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