Final Pay Check Template

FINAL PAY CHECK STATEMENT

Personal Information

Position Information

Hire Date:    Termination Date:    Final Pay Date:

Final Pay Calculation

Pay Period Covered: From to

Direct deposit applied to account ending:

Mailed check to current address

In-person pick-up by employee (ID verification required)

Deductions Authorization & Notices

By signing below, Employee acknowledges receipt of the amounts shown above and authorizes the Employer to make lawful deductions for taxes, court-ordered garnishments, benefit premiums, and repayment of any overpayments in accordance with Employer policy and applicable law. Employee further acknowledges that any errors in calculation will be corrected in a subsequent payroll or by separate billing as required by law.

Employee acknowledges that receipt of this final pay does not constitute a waiver of rights under federal, state, or local law. If a separate severance or separation agreement includes a release of claims, that document governs the scope of any waiver.

Authorization & Background Checks

Employee authorizes Employer to contact prior employers for verification of employment and to obtain consumer and/or investigative background reports where permitted by law. Employee certifies that the information provided in this document and the attached employment history is true and accurate to the best of Employee's knowledge.

I authorize contact with prior employers and consent to background checks as described above.

Employment History (Most Recent Employers)

Education

Graduation Date:

References

Legal Disclosures & Certification

At-Will Employment Statement: If applicable under state law, Employee's employment was at-will and either Employee or Employer may terminate the employment relationship at any time with or without cause, subject to any separate written agreement signed by both parties.

Equal Opportunity Statement: Employer maintains an equal opportunity policy and makes employment decisions without regard to protected characteristics as required by law.

Employee Certification: I certify that all information provided on this Final Pay Check Statement is true and complete. I acknowledge receipt of the final payment described herein. I understand that reporting any suspected payroll error promptly is my responsibility. I further acknowledge that this statement accurately reflects payments and deductions made as of the Final Pay Date unless otherwise noted in writing.

Authorization: I authorize the Employer to contact previous employers and to obtain background information as necessary to verify the representations I have made.

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