COMPANY NAME	YOUR LOGO
123 Main Street
Suite 456
City, State and Zip Code
Phone, Email
Website Address
PAYROLL DEDUCTION AUTHORIZATION

EMPLOYEE NAME	EMPLOYEE ID NUMBER
( LAST NAME )	( FIRST NAME )	( MIDDLE INITIAL )
SSN	DATE OF BIRTH	ACCOUNT NUMBER
WORK PHONE	PERSONAL PHONE	EMPLOYER NAME
PAY FREQUENCY	( X )	List amounts to allocate to the following accounts:
WEEKLY	ACCOUNT	AMOUNT ( $ )
BI-WEEKLY	(00)
SEMI-MONTHLY	CHK
MONTHLY	LOANS
OTHER	OTHER

AUTHORIZATION
I hereby authorize the Payroll Department of my employer to make regular deductions each payroll period from my payroll / salary / allotment in the amount of:
( ENTER AMOUNT, ABOVE )
The amounts will be credited, upon receipt, by:
( ENTER COMPANY NAME )
This payroll allocation request should begin:
( ENTER DATE )
EMPLOYEE NAME	EMPLOYEE SIGNATURE	DATE

FOR ACCOUNTING DEPARTMENT USE, ONLY	DATE OF RECEIPT	DATE OF UPDATE	UPDATED BY

PAYROLL DEDUCTION AUTHORIZATION

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