ACKNOWLEDGEMENT OF RECEIPT OF COMPANY PROPERTY

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information and all HR Support Center materials are provided in consultation with federal and state statutes and do not encompass other

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NOTE TO EMPLOYERS: Before deducting any monies from a final paycheck or other funds owed to the employee you

should ensure that this practice is legal in your state. Additionally, even if the practice is legal, you should be aware that

any deduction that would cause an employee to be paid less than minimum wage for hours worked will be a violation of

the Fair Labor Standards Act (FLSA) and state minimum wage requirements and could lead to significant penalties.

ACKNOWLEDGEMENT OF RECEIPT OF COMPANY PROPERTY

& FINANCIAL OBLIGATION FORM

Employee Name (Last, First, & Middle)

Employee ID Number

Date

Employee Title

Supervisor

Department

I commit to treating the company-issued equipment with reasonable care while I am employed, and

understand that intentional misuse, damage or negligent use of such equipment may subject me to

disciplinary action, up to and including termination. I hereby acknowledge receipt and assignment of the

following Company property:

☐ Office/Building Key

☐ Identification/Security Access Card

☐ Cell Phone

Inventory/Serial #:

☐ Computer

Inventory/Serial #:

☐ Uniform

List:

☐ Safety Equipment

List:

☐ Other Equipment

☐ Other

RETURN OF PROPERTY AND CLOSING OF ALL OPEN FINANCIAL OBLIGATIONS

In the event of my termination from employment, upon my last day of work or a date specified by my

supervisor, I will settle all open employee accounts (e.g., cash advances, credit card liabilities) in full and

return all tools and company property specified above, on an attached sheet, or that otherwise comes

into my possession.

If any property is not returned, I authorize a reasonable value for such items to be deducted from my

final paycheck, and if applicable, any final reimbursement owed to me. Should the company be unable

to collect from my final paycheck or other reimbursement, I acknowledge that the Company may invoice

Employee Signature: ______________________________________________ Date: _______________