Illinois Payroll Deduction Authorization


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                             This Payroll Deduction Authorization Notice can be used by an employer to withhold an
                             amount from an employee's earnings. A payroll deduction plan offers employees a
                             convenient way to automatically contribute income toward an ongoing expense. Typically,
                             the funds are put towards insurance, healthcare or an investment account. This
                             authorization form contains standard provisions and it may be customized to address the
                             specific needs of the employer or employee. This document should be used by employers
                             located in Illinois that offer a payroll deduction plan to employees.

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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 ($50)] per pay period from my paycheck, 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 Illinois Code, [STATUTE])

       a. Uniform usage fee, if required by Company. Reasonable replacement costs of keys,
          training manuals, tools, supplies, uniforms, etc. supplied to me by the Company,
          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 that is under my supervision and control as allowable by State

       [Instruction: Please amend the above code as per your specific requirements]

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, the Company is
   authorized to deduct the new amount from my pay.

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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

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]

© Copyright 2011 Docstoc Inc. registered document proprietary, copy not              3

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