Page 67 - City of Farmington Administrative Regulations

ATTACHMENT B
RECEIPT OF CLOTHING AND 63
AUTHORIZATION FOR PAYROLL DEDUCTION

I am employed by the City of Farmington and I hereby acknowledge receipt of, or subsidy for,
the following items of clothing.:

Qty Price (each} Totat
long-sleeved work shirts $ $
Short-sleeved work shirts $ $
long-sleeved t-shirts $ $
Short-sleeved t-shirts $ $

Polo shirts $ $
Jeans/denim pants $ $
Cargo pants $ $
Shoes - subsidized amount $ $
Jacket/coat $ $
Vest $ $
Coveralls/overalls $ $

City patches $ $
Complete uniform $ $
Other (describe) $ $

Total Value of Clothing Reeelved $

I understand that all items as provided above remain the property of the City. Upon separation
of my employment with the City, I will return these items or will reimburse the City for the
unused portion of these items according to the pro-rata schedule set out below. I understand,
and hereby authorize, that if I have not returned the above items prior to the time my final
paycheck is prepared, that a payroll deduction will be entered against my final paycheck in an
amount according to the following pro-rata schedule:
Period of employment from Percent of cost to be
date of issuance reimbursed
0-30 days 100%
31-60 days 80%
61-90 days 60%
91-120 days 40%
121-150 days 20%
151-180 days 10%
181 days+ 0%

Received and dated this __ day of ______ . 20_.

Signature

cc: Personnet Print Name: -----------

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