Employee Time Off Adjustment

EMPLOYEE TIME OFF ADJUSTMENT
Name*
I acknowledge that on the dates listed below, I did not submit a time off request for days/hours which I did not work. I agree to reimburse Therapy West, Inc and/or make the following adjustments.
Dates that were not requested as time off*
Hours to be adjusted *
I would have submitted the time off as unpaid and thus authorize Therapy West to deduct the overpayment amount from my next paycheck.I would have submitted the time off as unpaid and thus will remit an overpayment amount with a personal check within the next week.I would like the hours to be adjusted by using my vacation time.I would like the hours to be adjusted by using my sick time.I would like the hours to be adjusted by using my continuing education hours (only to be used at the direction of the owners).Type option 5
The session tracking sheet will be updated accordingly.

Regardless of the selection above, if employment ends, I understand that the full amount will become due immediately. Some or all may be collected from my final paycheck if allowed by state law. Therapy West, Inc may seek to recoup any remaining funds through other means.

I have read this acknowledgment and voluntarily agree to the indicated repayment terms.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

EMPLOYEE TIME OFF ADJUSTMENT