Fill and Sign the Assignment of Wages Form

Assignment of a Specified Amount of Wages Assignment made on the _________________ (date) , by __________________ (Name of Assignor) of ____________________________________________________ (street address, city, state, zip code) , referred to herein as I or me , in favor of _____________________ (Name of Assignee) , of _____________________________ _______________________________ (street address, city, state, zip code) , referred to herein as Assignee. 1. Wages Involved For value received, I hereby assign to Assignee $_________ of salary or wages earned by me up to and including ______________ (date) , while employed as ________________________________ (state occupation or position) , by ______________________________ (Name of Employer) , of ____________________ ____________________________________ (street address, city, state, zip code) . 2. Authorization to Employer A. I authorize my Employer to pay the above-stated amount to Assignee, on presentation of this Assignment. B. When my Employer has paid all or a portion of that amount in accordance with this Assignment, this Assignment shall constitute a receipt against me for such amount. C. I hereby release and forever discharge my Employer from any liability to me by reason of the payment of all or a portion of that amount to Assignee pursuant to this Assignment. 3. Attorney-in-Fact . I appoint Assignee, his representatives or assigns, as my attorney-in-fact, to sign any checks, vouchers, or receipts necessary to collect all or any portion of the above-stated amount of my wages from my Employer, and to evidence payment of such amount. 4. Warranties I warrant and represent that: A. I am over twenty-one years of age; B. I am not indebted to my employer; C. My Employer owes me the above-stated amount over and above all deductions; D. I have not, prior to the effective date of this Assignment, sold, assigned, or otherwise disposed of the above-stated salary or wages; and E. There are no orders, garnishments, or attachments outstanding affecting the above-stated salary or wages in any way. 5. Nature of Transaction A. This transaction is absolute and unconditional. B. This transaction is an original transaction and not a renewal or extension of any kind, and has no connection with any other transaction that I may have had with Assignee prior to the effective date of this Assignment. 6. Bankruptcy of Employer. Assignee shall assume all risks of loss that may now exist or subsequently arise due to the insolvency or bankruptcy of my Employer. 7. Severability The invalidity of any portion of this Assignment will not and shall not be deemed to affect the validity of any other provision. If any provision of this Assignment is held to be invalid, the parties agree that the remaining provisions shall be deemed to be in full force and effect as if they had been executed by both parties subsequent to the expungement of the invalid provision. 8. No Waiver The failure of either party to this Assignment to insist upon the performance of any of the terms and conditions of this Assignment, or the waiver of any breach of any of the terms and conditions of this Assignment, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred. 9. Governing Law This Assignment shall be governed by, construed, and enforced in accordance with the laws of the State of __________________ (name of state). 10. Mandatory Arbitration Notwithstanding the foregoing, and anything herein to the contrary, any dispute under this Assignment shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect. Witness my signature this the _____ day of ______________, 20_____. _____________________________ (Signature of Assignor) _____________________________ (Printed Name of Assignor)