Payroll Deduction Authorization Form
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1PAYROLL DEDUCTION AUTHORIZATION FORM
Employee Name:
___________________SSN: _____________
Deduction Effective Date: ___________________
Payroll Deductions:
401(k)
% or $______________
q
401(k) Loan
$______________
q
Health
$______________
q
Employee Loans
$______________
q
Other _________________
$______________
q
I agree that my gross pay will be reduced by the amount of my deduction as checked
and indicated above.
In the event of a deduction change during the year, my
employer is authorized to deduct the new amount from my pay.
In the event a new Employee Deduction Authorization Form is not executed on or
before the next year-end, this form shall be deemed to continue in force for the next
succeeding year.
Employee Signature: _____________________ Date:___________
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Parent category: Business