Payroll Withholding Authorization Form printable pdf download

Payroll Withholding Authorization Form

PAYROLL WITHHOLDING

AUTHORIZATION FORM

PURPOSE: Monthly Payroll Deduction (In this section, enter the amount you want

deducted each month.)

%________________ AUL (403 (b))

$________________ S125 (Pre-Tax) Child Care Deductions (PSA)

$________________ S125 (Pre-Tax) Health Related Expenses (PSA)

$________________ S125 (Pre-Tax) Supplemental Premium Account (PSA)

$________________ Dependent Medical (pre-tax) Insurance Premiums

$________________ Dependent Dental (pre-tax) Insurance Premiums

$________________ Summer Insurance Co-pay Deduction

$________________ Tax deductible donation to UMCHS

$________________ UMCHS Child Care Deduction

$________________ Other ___________________________________

(please specify)

Note, in this section, enter the amount you want deducted per pay period.

Amount to be withheld each pay period $__________________%_________________

Beginning date ______________________ Ending date _________________________

Signing this form acknowledges consent for these deductions to be taken from your

paycheck.

Employee Name (please print) ______________________________________________

______________________________________

Date _________________________

Employee Signature

************************************************************************

Fiscal Department Use Only

Date Entered ___________________________ by _______________________________

Payroll Withholding Authorization Form