Payroll Deduction Authorization Form

A payroll deduction authorization form is filled by an employee, giving permission to the employer, a financial institution or any other entity to deduct a certain amount of money from his wage.  This deduction can be effected within specified months or years.  The amount of each deduction is also indicated on the payroll deduction authorization form.

PAYROLL DEDUCTION AUTHORIZATION FORM

Please fill the payroll deduction authorization form to start, stop or modify existing deduction.  The filled form should be duly signed and submitted to the payroll office.  Note that to modify or stop the deduction details, a new payroll deduction authorization form must be filled.

Employee Information

Full Name: __________________________________ Date of Birth: ________________

Social Security Number: ______________ Employee Number / Employment reference ____

Company name _________________________ Position ___________________________

Phone: ________________________________ Email: ____________________________

Address: _______________________________ Town: ____________________________

Zip: ______________________________ State: __________________________________

I hereby authorize my employer to initiate payroll deduction from my monthly salary from __________

to _____________ amounting to ___________ payable to:

Full Name: _____________________________ Social Security Number: ______________

Company name ________________________ Position ___________________________

Phone: _______________________________ Email: ____________________________

Address: _____________________________ Town: ____________________________

Zip: _________________________________ State: ____________________________

Employee signature: ____________________________ Date: _______________________