DIY Legal Forms

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Assignment of Wages & Other Compensation

01. Identification of Parties. This Assignment is made by this ________ day of ________ [month] 20__, by ________ [name], residing at ________ [address] hereinafter referred to as "Assignor" in favor of ________ [name], with offices at ________ [address] hereinafter referred to as "Assignee".

02. Consideration for Assignment. The consideration for this Assignment and the transaction giving rise to it is [consideration].

03. Description of Assignment. Assignor assigns to Assignee an interest in Assignor's salary, wages, and other compensation for work, labor, and services now due or to become due from Assignor's employer, [name], with offices at [address]. The interest assigned by this Instrument is equal to ---------- dollars ($----------) with interest at the rate of ---------- percent (----------%) per annum from [date].

04. Size of Periodic Payments. Assignor's salary, wages, and other compensation are paid to Assignor weekly. The amounts to be paid to Assignee shall be ---------- percent (----------%) of the gross amount of the weekly compensation received by Assignor, or any larger or smaller sum allowed by law, now or in the future.

05. Authorisation to Assignor's Employer. Assignor authorises his employer to pay the sums assigned to Assignee in accordance with the terms of this Assignment until the total amount assigned has been paid in full. Assignor agrees to hold his employer harmless by reason of these payments.

06. No Other Assignment. Assignor has made no other assignment of and no order of any court has been entered against Assignor's wages, salary, or other compensation in favor of Assignee or any other party.

07. Severability. Should any Court hold that any portion of this Assignment is invalid, the remainder shall be in full force and effect, and the invalid portion shall be struck from the Assignment or modified as the Court shall order.

08. Representations. Neither party has made any representations nor promises, other than those contained in this Assignment or in some further writing signed by the party making the representation or promise.

09. This Assignment binds and benefits both parties and any successors. This document, including any attachments, is the entire Assignment between the parties.

10. Execution. This Assignment was executed on [date], in [city, state]. Assignor acknowledges the delivery to Assignor of a copy of this Instrument.

IN WITNESS WHEREOF, the parties hereto have caused this instrument to be executed in triplicate on the day and year first above written.








State of ________)

) SS.:

County of________)

On ________, before me, ________, Notary Public, personally appeared ________, who proved to me on the basis of satisfactory evidence to be the person(s) whose names(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies) and that by his/her/their signatures on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under the PENALTY OF PERJURY under the laws of the State of _________ that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.


Name of Notary

Notary Public

My Commission Expires