Massachusetts General Laws
Chapter 154 - Assignment of Wages
Section 5 - Standard Form

Section 5. The standard form of assignment shall be as follows:
Know All Men by these Presents.
That I, of in the county of , for a valuable consideration, to me paid by , of , the receipt whereof I do hereby acknowledge, do hereby assign and transfer to said all claims and demands, not exempt by law (which I now have, and all) which within a period of from the date hereof I may and shall have against my present employer, and against any person whose employ I shall hereafter enter, (for all sums of money due and) for all sums of money and demands which, at any time within said period may and shall become due to me, for services as . To have and to hold the same to the said , his executors, administrators and assigns, to secure a debt
(1) Of dollars (with interest thereon from , at the rate of per cent per annum), for money (or goods) actually furnished by the assignee amounting to dollars.
(2) Contracted prior to the execution of this assignment (or contracted simultaneously with the execution of this assignment).
(3) Three fourths of the weekly earnings or wages, which are dollars, are exempt from this assignment.
(4)1Ten dollars per week, as earned, is exempt from this assignment.
In Witness Whereof, I have set my hand this day of .
Signed and delivered, in presence of h. m. M. Received and entered in records of assignment of wages in clerk's office of the of , book , page .
, Clerk.
1Clause (4) to be used in place of clause (3) only for assignment under section 2.

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