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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.


(use the Tab key to move forward a field and Shift-Tab to move back a field)
Company Name:
Street Address:
City:
State:    Zip Code: 
Telephone Number:
E-Mail Address:



 
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)

_______________________________________________


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