Assignment of Wages
This assignment is made by (Name of Assignor), of (street address, city, state,
zip code), hereinafter called Assignor, in favor of (Name of Assignee), of (street
address, city, state, zip code), hereinafter called Assignee.
For and in consideration of the mutual covenants contained in this Agreement,
and other good and valuable consideration, the undersigned Assignor agrees as
1. The undersigned Assignor does hereby assign Assignee $___________ out of
my wages (or salary) to be earned and payable to me by (Name of Employer) of street
address, city, state, zip code), for work to be performed by me as (name of occupation
or position), during the period of (date) and (date).
2. 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 (e.g., money or
goods) actually furnished by Assignee to me amounting to $____________, contracted
for by me (e.g., prior to or simultaneously with) the execution of this Assignment.
3. The undersigned Assignor does hereby certify