Payroll
Policy
FIACCT 11-11_00 Payroll – Request for Pay Advance Payroll Deduction Form FI 23
Effective: September 15, 1989
Revised: March 6, 2017
Reviewed: March 10, 2017
Purpose
The purpose of the Request for Pay Advance Payroll Deduction, form FI 23, is to allow the employee to
request a payroll deduction each payday to pay back his Pay Advance (see policy FIACCT 11-10.00 Pay Advance Payroll Deduction). This form is available through the DAS Division of Finance website at finance.utah.gov.
Instructions for Entry
Field
Description
Employee Identification
Number
The employee’s Employee Identification Number.
Print Employee Name
Print the name of the employee (as it appears on the Payroll System) desiring the payroll deduction for the Pay Advance.
$
Dollar amount to be deducted each payday. Minimum deduction is $5.00 per payday.
Beginning With Payday
The calendar date of the payday that the payroll deduction for the PayAdvance is to begin.
Employee Signature
The signature of the employee.
Date
The date that the employee signs the Request for Pay Advance Payroll.