Miscellaneous Employee Payroll Deduction printable pdf download

MISCELLANEOUS EMPLOYEE PAYROLL DEDUCTION

PAYROLL AUTHORIZATION FORM

Complete your 1) employee information, 2) deduction amount, 3) sign and date at the bottom and return this form to your payroll contact.

1) Complete your employee information. (Please Print)

Employee Name _________________________________________________________Social Security Number _XXX_-_XX_-_________

Employer / Client Name ___________________________________________________________________________________________

2) Amount to be deducted and credited to client on payroll invoice. (Please Print)

Reason for advance: ___________________________________________________________________________________________

_____________________________________________________________________________________________________________.

Amount to deduct per paycheck $__________________Total Amount to be repaid $_____________________

Payroll deductions will begin on the first scheduled payroll after receipt of this form. Pay period beginning date ______/______/______

Acknowledgement of advance and deduction amounts have been reviewed and agreed to.

Employer / Client Signature _________________________________________________________________ Date_____/_____/_____

Printed Name and Title ____________________________________________________________________

3) Sign, date, and return the completed authorization form to your payroll contact.

I authorize Employers Resource to deduct the stated amount per paycheck until the total amount is collected. In the event my employment

status changes (including termination of employment) during the deduction repayment period, I hereby authorize Employers Resource to

deduct the remaining balance due from my final paycheck and/or pending reimbursements. In the event the total amount cannot be

satisfied, I understand that this is a legally binding agreement and any balance is due immediately to my employer / client of Employers

Resource.

Employee Signature________________________________________________________________________ Date_____/_____/_____

OpsForm-MiscDed-Sep14

Miscellaneous Employee Payroll Deduction