An itemized confirmation of final compensation — salary through the last day, accrued PTO payout, reimbursements, and other amounts — acknowledged by the employee and countersigned by the company.
This acknowledgment itemizes the components of a departing employee's final pay and records that both parties have reviewed them. It creates a clear, shared record of what was paid, when, and how.
Company name (the "Company") and Employee full name (the "Employee") confirm that the Employee's last day of employment is Last day of employment.
| Component | Gross amount |
|---|---|
| Salary earned through the last day | Final salary amount |
| Accrued, unused paid time off | PTO payout amount |
| Approved expense reimbursements | Expense reimbursement amount |
| Other: Other payments description | Other payments amount |
| Total gross final pay | Total final pay amount |
Components that do not apply should say "none". Amounts are gross and subject to legally required withholdings and any deductions the Employee has authorized in writing.
The total will be paid on Payment date by Payment method.
Employee: ✍ Employee signature Date: Employee signature date
For the Company: Company representative name and title
Signature: ✍ Company signature Date: Company signature date
Highlighted fields are filled in when you customize and send this document on Diiirect.
Jurisdiction note
Final-pay deadlines, mandatory payout of accrued vacation, permitted deductions, and whether an acknowledgment like this can limit later claims are regulated differently in each jurisdiction. Confirm local requirements with counsel before relying on this document.
Not legal advice
This template is provided for general informational purposes only and is not legal advice. Laws differ by jurisdiction and change over time — have a qualified professional review any document before you rely on it.
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