Final Paycheck Acknowledgment
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I, the undersigned recipient, have received my final paycheck from:
______________________________
Company
The total amount of the paycheck is: $
__________
Paycheck amount represents:
Wages $
__________
Accrued Vacation Pay $
__________
Other
_________________________ $ __________
_________________________ $ __________
_________________________ $ __________
_________________________ $ __________
_________________________ $ __________
Deductions
_________________________ $ __________
_________________________ $ __________
_________________________ $ __________
_________________________ $ __________
_________________________ $ __________
_________________________ $ __________
_________________________ $ __________
To the best of my knowledge, there is no additional money owed to me by the employer at the present time.
______________________________
Name of Recipient
________________________________________________________ __________
Signature of Recipient Date
________________________________________________________ __________
Signature of Person Issuing Final Paycheck Date
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