Payroll Deduction Authorization

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

NOTE: Please keep a copy of this form for your records.