Payroll Deduction
Authorization
ocstoc Legal Agreements
This Payroll Deduction Authorization Notice can be used by a
Company/Employer to withhold an amount from Employee’s earning. It is
an authorization form for employee to sign for deductions.
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Attorney Drafted
1
PAYROLL DEDUCTION AUTHORIZATION
Company/Department: ____________________ [Instruction: Insert the name of Company]
Employee Name: _________________________ [Instruction: Insert the name of Employee]
Employee ID Number: _______________ [Instruction: Insert Employee ID number (if any)]
Work E-mail Address: _______________ [Instruction: Insert E-mail address of Employee]
Work Telephone Number: __________ [Instruction: Insert telephone number of Employee]
Deduction Effective Date: ____ [Month] ____ [Date], 20__
1. I hereby authorize _________________ [Instruction: Insert the name of Company] to
initiate a payroll deduction to deduct ________ ($___) [Instruction: Insert the Deduction
amount E.g., fifty dollars only ($ 50)] per pay period from my paycheck for the following
effective with the pay date of ____ [Month] ____ [Date], 20____ for any compensation that
may be due to me up to and including the total amount of any of the following:
Payroll Deduction Codes:
(Under California Code, Labor Code, Article 1 – General Occupations)
a. Uniform usage fee, if required by client. Reasonable replacement costs of keys,
training manuals, tools, supplies, uniforms, etc. supplied to me by the Client which
are not returned upon request.
b. Education expense reimbursed to me by employer, if termination occurs within
______ (___) [◊six (6)] months of completion of the course. Stop payment fees for
lost or destroyed payroll checks.
c. Drawer Shortage which is under my supervision and control as allowable by State
jurisdiction.
[Instruction: Please amend the above code as per your specific requirements]
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2. I understand that if I am initiating or changing a payroll deduction, the deduction may not be
made if I have insufficient income in a pay period to cover this and all other required (e.g.,
taxes) and authorized deductions, and will not hold the Company liable for any deductions
not made.
3. I agree that my gross pay will be reduced by the amount of my deductions as checked and
indicated above. In the event of a deduction change during the year, Company is authorized
to deduct the new amount from my pay.
4. I understand that this is a condition of employment and that I am obligated to pay all monies
due to the company upon termination, resignation or failure to reappear at my place of
employment
5. I agree that in the event a new or amended Employee Deduction Authorization Form is not
executed on or before the next year-end, this form shall be deemed to continue in force for
the next succeeding year.
____ [Month] ____ [Date], 20____
____________________________________
[Instruction: Insert the name of Employee]
__________________________________________
[Instruction: Insert the signature of Employee]
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