EMPLOYEE NAME	DATE of FORM
EMPLOYEE ID	SSN	DATE EFFECTIVE
POSITION TITLE	DEPARTMENT

PAYROLL DEDUCTION FORM TEMPLATE

DEDUCTION DESCRIPTION

X	TYPE DESCRIPTION	%	AMOUNT	X	TYPE DESCRIPTION	%	AMOUNT
401(k)	OTHER
401(k) LOAN	OTHER
HEALTH	OTHER
EMPLOYEE LOAN	OTHER

ADDITIONAL INFO

AUTHORIZATION

I UNDERSTAND THAT THIS FORM AUTHORIZES THE REDUCTION OF GROSS PAY BY THE AMOUNT OF DEDUCTIONS INDICATED ABOVE. MY EMPLOYER IS AUTHORIZED TO DEDUCT A DIFFERENT AMOUNT SHOULD THERE BE A DEDUCTION CHANGE THROUGHOUT THE YEAR. THIS DOCUMENT AUTHORIZES THE CONTIUATION OF DEDUCTIONS TO THE NEXT YEAR SHOULD A NEW FORM NOT BE SUBMITTED BEFORE YEAR-END.

EMPLOYEE SIGNATURE	DATE

PAYROLL REPRESENTATIVE	DATE

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