I,                                                      , request an advance payment of $                on my wages payable on the payroll date of                     I understand that I am eligible for no more than 10 emergency payroll advances per calendar year and that the amount requested shall not exceed 25% of my average weekly earnings.  If this request is approved, I would like to receive this advance by                              . By signing this form, I authorize Annie M's Cafe, LLC to make deductions from my paycheck to repay this advance through either: 1) one payroll deduction to be made from wages payable the first pay period immediately following the pay period from which this advance is made or: 2) from 2 equal deductions from the next 2 pay periods immediately following the pay period from which this advance is made.  I also agree that if I terminate employment prior to total repayment of this advance, I authorize Annie M's Cafe, LLC to deduct any unpaid advance amount from any wages owed to me at the time of termination of employment.