PAYROLL DEDUCTION AUTHORIZATION The undersigned hereby authorizes______________________________ to deduct $__________ from my gross earnings each payroll period beginning, the following:
In payment for:
Amount:
_____Credit Union _____Employee Savings Plan _____401 K Plan _____Union Dues ___ _______________________ ___ _______________________ ___ _______________________ ___ _______________________ Total
$_______.__ _______.__ _______.__ _______.__ _______.__ _______.__ _______.__ _______.__ $_______.__
Signature_______________________________Date________________________ Print Name__________________________________________________________ Social Security Number______________________________________________
Please keep a copy of this for your records.