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Authorization For Payroll Deduction Uniform Rental/Laundry Service

THIS IS A SAMPLE OF AN AUTHORIZATION FOR PAYROLL DEDUCTION FORM  FOR UNIFORM RENTAL/LAUNDRY SERVICE, 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 PAYROLL DEDUCTIONS, PLEASE COMPLETE THE ITEMS BELOW AND YOUR COMPANY WILL BE CONSIDERED FOR APPROVAL AND NOTIFIED BY MAIL.


(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: 
Person Requesting Form
Telephone Number:
E-Mail Address:


 
Employer Name: ______________________________________________
Employer
Mailing Address:
______________________________________________
 
I,
 
   hereby authorize
 
  to deduct
 

(employee's name)

 

(employer name)

 
 $
 
  per pay period from my wages starting the pay period ending
 
 

(amount)

 

(date)

for my uniform rental or laundry service.  I reserve the right to revoke this payroll deduction authorization at any time.  I agree to return all uniforms when I terminate this authorization or my employment. If I fail to return all the uniforms issued to me, I authorize
 
   to deduct from my final paycheck the replacement cost for such uniforms as outlined in the

(employer name)

 
schedule below. If there is a dispute as to the return of uniforms, no deductions shall be made.

 
Signature  __________________________________ Date  _________________

 
 
Description
Size
Weekly # Cleaned
Weekly # Supplied
Weekly Rental Charge
Quantity Ordered
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

TABLE OF VALUES

New 100% of Costs
6 months old 65% of Costs
1 year old 35% of Costs
1-1/2 years old 10% of Costs
over 2 years old -----------------
 

TO DISCONTINUE THE PAYROLL DEDUCTION

I wish to discontinue the payroll authorization above, effective pay period ending  
 

(date)

____________________________________
                   (signature)


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