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Payroll Deduction Authorization

Click here for completed sample. Bolded items are examples of completed fields from this form.

Your Name:
Social Security #:
(Your Social Security Number)
Employer:
(Name of company for which you work)
Indicate below to what you want your payroll deduction by entering amounts next to the item (e.g., if you want per paycheck to go to your Credit Union account, indicate 50.00 under the "Amount" heading next to "Credit Union"). There are also three blanks to indicate other options not listed. For example, if you'd like 50.00 per paycheck to go to a money market account you have set up with your bank, indicate the account number under the "Other" heading and enter "50.00" under the "Amount" heading. You can also enter amounts for more than one place you want deductions. For example, if you want money taken from your paycheck for Credit Union and Union Dues, enter amounts next to each in the text fields under the "Amount" heading. The program will automatically total your deductions for you.
Apply deduction towards:Amount
401K Plan
Employee Savings Plan
Credit Union
Union Dues
Other:
Effective Date://
(Select the month, day and year you want the payroll deduction to become effective)