Fill and Sign the Assignment or Form

Assignment of Wages Due or to Become Due Assignment made on the _______________ (date), by ____________________ (Name of Assignor) of ____________________________________________________ _____________ (street address, city, state, zip code) , referred to herein as Assignor, in favor of _________________________ (Name of Assignee), of ___________________ _________________________________ (street address, city, state, zip code) , referred to herein as Assignee. For and in consideration of the covenants contained in this Assignment, and other good and valuable consideration: A. Assignor does hereby assign to Assignee $____________out of the ____________ (wages or salary) ____________ (earned or to be earned) and payable to me by ____________________ (Name of Employer), of _______________________ ________________________________________ (street address, city, state, zip code) , referred to herein as Employer, for work _____________________ (performed or to be performed) by me as _____________________ (name of occupation or position) , during a period of _____ (number) _____ (months) from the date of this Assignment. B. This Assignment is given to Assignee to satisfy a debt of $_____________, with interest on such debt from __________________ ( date) , at the rate of _______% per annum, for _____________ (money or goods) actually furnished by Assignee amounting to $___________, contracted for by me ______________________ (prior to or simultaneously with) the execution of this Assignment. C. The undersigned Assignor is a married adult. D. No other Assignment or order exists in connection with the transaction set forth above that gives rise to this Assignment. E. I authorize my Employer, during the period stated in this Assignment, to pay the claim to Assignee until the full amount owed by me to Assignee set forth above is fully paid. F. I also authorize Assignee to take all legal measures that may be proper or necessary for the complete recovery of the claim assigned, and to receive any money that may become due, and pursuant to such authorization, appoint Assignee as my attorney-in-fact to collect all checks or money payable to me under this Assignment, and to endorse my name to any checks or other negotiable instruments payable to me and issued by my present Employer for the term of this Assignment, until the claim of Assignee is fully satisfied. Witness my signature this the _____ day of ______________, 20_____. _____________________________ (Signature of Assignor) _____________________________ (Printed Name of Assignor)