Payroll Draw Request

REQUEST FOR A PAYROLL ADVANCE

Payroll Advances may be requested only one-time per month. Request are due by the 10th of the month, with funds direct deposited on the 15th. Payroll Advances can be one time or set up as recurring.
For the Month Of*
Year*
Submission Date*

MonthDayYear
A. EMPLOYEE INFORMATION:
Full Name*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Payment Disposition

Direct DepositMail to the address in Paylocity
Please check one:*

Hourly EmployeeSalaried Employee
Frequency*

One-TimeReoccurringCancel Reoccurring
Amount Requested
Advance Amount*

Max - 70% of your gross earnings by the 15th of the monthFlat Amount
*

I Agree
By typing my name I authorize Oregon Coast Community College to deduct from my next regular paycheck the amount of the advance requested above.
Should be Empty:

REQUEST FOR A PAYROLL ADVANCE