|
Authorization For Payroll Deduction
|
THIS IS A SAMPLE OF AN AUTHORIZATION FOR PAYROLL DEDUCTION
FORM, CONNECTICUT STATUTE 31-71e, FOR YOUR USE. THIS IS JUST A
SAMPLE, AND IS NOT TO BE COMPLETED. IF YOU WISH TO USE IT TO
AUTHORIZE ANY ITEMS LISTED FOR PAYROLL DEDUCTION, PLEASE COMPLETE THE
INFORMATION IMMEDIATELY BELOW AND YOUR COMPANY WILL BE CONSIDERED FOR APPROVAL
AND NOTIFIED BY MAIL. A REQUEST FOR ANY ADDITIONAL PAYROLL DEDUCTION ITEMS
MUST BE SUBMITTED SEPARATELY. |
| Employer Name: |
______________________________________________ |
|
|
Employer
Mailing Address: |
______________________________________________ |
|
|
| Employee Name
(PLEASE PRINT FULL NAME) |
Social Security # |
*Employee # (*if
applicable) |
|
______________________________________________ |
________________ |
________________________ |
| |
|
|
I hereby authorize (employer name) ________________________
to deduct (amount) $______________ per pay period
from my paycheck for (enter payroll deduction code #)
________________________ starting the pay period ending
(date) _________.
Deductions that are sent to a third party
(bank, credit union, etc.) shall be transmitted within three working days from
the deduction date.
PAYROLL DEDUCTION CODES:
(as shown on pay stub)
A.
Life Insurance Premium
B. Loan (define type and dollar
amount):
|
___________________________________________________________ |
C. Employee Purchases
(define items purchased and dollar amount):
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________ |
D. Pension Plan
Employee Contribution
E. Payroll Savings Plan (to be
deposited into employee's individual savings bank
account
#______________________________
F. United Way Contribution
G. Christmas/Hanukkah Club (to be
deposited into employee's individual savings bank
account
#______________________________
H. Credit Union:
Name
____________________________
Address
____________________________
TO DISCONTINUE THE PAYROLL DEDUCTION
I wish to discontinue the payroll authorization
above, effective pay period ending (date) _____________ .
(signature)
_______________________________________________ |
