PAYROLL DEDUCTION AUTHORIZATION
I, ___________________________ authorize deduction from my gross earnings for the following specified items and amounts:
IN PAYMENT FOR: AMOUNT
[ ] Credit Union _________.___
[ ] Employee Savings Plan _________.___
[ ] 401 K Plan _________.___
[ ] Union Dues _________.___
to be deducted each payroll period beginning _____________________.
Signature __________________________ Date ________________
Print Name ________________________
Social Security # ______-______-______
Please keep a copy of this for your records.
These forms are provided AS IS. They may not be any good. Even if they are good in one jurisdiction, they may not work in another. And the facts of your situation may make these forms inappropriate for you. They are for informational purposes only, and you should consult an attorney before using them.