Employee PILON Demand

EMPLOYEE PILON DEMAND

Personal Information

Employer Information

Position Information

Demand Details — Payment In Lieu of Notice (PILON)

This document constitutes a formal demand by Employee Name: to Employer Name: for payment of wages, benefits and other amounts owed due to termination without contractual notice or payment in lieu thereof.

Contractual or statutory notice required: . Employee asserts entitlement to PILON covering the notice period of .

Amounts Demanded — Itemized

Base salary or wages due for notice period: $ (calculation basis: ).

Accrued but unused vacation / PTO: $.    Unpaid bonuses / commissions: $

Employer-paid benefits continuation owed (COBRA/insurance adjustments): $.

Other amounts (describe): $

Total amount demanded (gross): $. Employee requests gross payment to be issued without delay and subject to lawful deductions only.

Deductions, Taxes, Net Pay

Employee requests itemized statement of all deductions and withholdings applicable to the amounts demanded. Employee requests payment be issued as: Gross amount, with Employer responsible for lawful taxes and deductions Net amount after taxes

Supporting Documents Checklist

The undersigned attaches or will provide the following documents in support of this demand (check all that apply):

Remedies, Deadline and Interest

Employee demands payment of the Total amount demanded by Employer within days of receipt of this demand. Failure to satisfy this demand within the stated period will result in Employee pursuing all available remedies at law or equity, including but not limited to a claim for unpaid wages, liquidated damages, prejudgment interest, attorneys' fees and costs.

Interest on unpaid sums is asserted at the rate of from the date of termination until paid in full, to the extent permitted by law.

Legal Statements and Certifications

At-Will Employment: The undersigned acknowledges that employment may be at-will unless otherwise modified in a written agreement. Nothing in this demand alters any express provision of a valid written employment agreement to the contrary unless expressly agreed in writing by the parties.

Equal Employment Opportunity: The undersigned reaffirms all rights under applicable equal employment opportunity laws and asserts that this demand is made without waiver of any statutory claims, unless expressly stated in a signed settlement.

Applicant Certification & Authorization

I certify that all information provided in this Employee PILON Demand is true, accurate and complete to the best of my knowledge. I authorize Employer to verify employment-related information and payroll records necessary to investigate this demand. I understand that knowingly presenting false information may subject me to legal penalties.

Employment History (Most Recent Employers)

Education

References

Employee Statement (Optional)

Acknowledgement

By signing below, I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge and that I am the person entitled to the payments and remedies sought herein. I further authorize Employer to communicate with my designated representatives and to disclose payroll and employment records as reasonably necessary to resolve this demand.

Sign Now