Payroll Deduction Authorization Form

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Payroll Deduction Authorization Form 
[Charitable Contribution to the Motion Picture & Television Fund] 
 
Please fax this form to (818) 876‐1943 (confidential fax, no cover sheet necessary.) 
 
Payroll Deduction Information
 
 
1. 
I wish to give $_______ per paycheck 
 
2. 
I wish to give _______% per paycheck (Minimum 0.5%) 
 
 
 
Starting Date  ________________      
Employee Information
 
 
Employee Name   ____________________________________________________ 
 
Social Security Number  ___________/_____________/_____________________ 
 
Employee Mailing Address   ____________________________________________ 
 
City ____________________________   State __________   Zip _______________ 
 
Email Address _______________________________________________________ 
 
Employee Daytime Phone or Message Phone ( ______ ) ________ ‐ ____________ 
 
Employer Information
 
Employer __________________________________________________________ 
 
Employer Mailing Address  ____________________________________________ 
 
City ____________________________   State __________   Zip _______________ 
 
 
Union/IATSE Local Affiliation ___________________________________________
 
 
 
I authorize my employer or payroll company to make an automatic contribution from 
my paycheck, as noted.  (May be cancelled with written notice at any time.) 
 
Signature ____________________________________________  Date ______________ 

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