Payroll Deduction Authorization Form

PAYROLL DEDUCTION AUTHORIZATION FORM

Employee Name: ______

Designation: ______ID # ______

Department: ______

I hereby authorize (add name of the company here) to make the following deductions from my gross earnings every month, start from (starting month) and ending at (end month)

401(k) Plan / $ / % of net pay
Employee savings Plan / $ / % of net pay
Loan Repayment to ______/ $ / % of net pay
Union Dues / $ / % of net pay
TOTAL

Total (in words) ______

I understand that the deduction may not be made if I have insufficient income in a pay period

I understand that statutory dues such as Income Tax and Social Security Tax take precedence over these deductions

I understand that the deductions may not take effect during the current payroll cycle

I will not hold the company liable for any deductions made or not made

Signature:

Name:

Date:

FOR PAYROLL USE

Received on (date) Initials ______

Action Taken on (date) Initials ______