PAYROLL DEDUCTION AUTHORIZATION - TYPE A
I authorize __________________
To deduct $ _________________ from my gross earnings each payroll period beginning _____________________.
IN PAYMENT FOR:
AMOUNT
[ ] Credit Union
_________.___
[ ] Employee Savings Plan
_________.___
[ ] 401 K Plan
_________.___
[ ] Union Dues [ ] _________________
_________.___ _________.___
Total
$_________.___
Signature __________________________
Date ________________
Print Name ________________________
Social Security # ______-______-______ Please keep a copy of this for your records.