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PAYROLL DEDUCTION AUTHORIZATION
The undersigned hereby authorizes_______________________________ (name of company) to deduct a total of $_______________ from my gross earnings each payroll period beginning _________________ (date), as follows:
| In payment for: | Amount: |
| ___ Credit Union |
$_________._____ |
| ___ Employee Savings Plan | $_________._____ |
| ___ 401(k) Plan | $_________._____ |
| ___ Union Dues | $_________._____ |
| ___ _____________________________ | $_________._____ |
| ___ _____________________________ | $_________._____ |
| ___ _____________________________ | $_________._____ |
| ___ _____________________________ | $_________._____ |
| Total |
$_________._____ |
| _______________________________________ Signature |
________________ Date |
|
_______________________________________ Printed Name _______________________________________ Social Security Number |
