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Authorization For Payroll Deduction
Uniform Rental/Laundry Service
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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. |
| Employer Name: |
______________________________________________ |
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Employer
Mailing Address: |
______________________________________________ |
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| I, |
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hereby authorize |
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to
deduct |
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(employee's name) |
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(employer name) |
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| $ |
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per pay period from my wages starting the pay period ending |
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(amount) |
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(date) |
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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 |
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to deduct from my final paycheck the
replacement cost for such uniforms as outlined in the
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(employer name) |
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schedule below. If there is a dispute as to
the return of uniforms, no deductions shall be made. |
| Signature
__________________________________ |
Date _________________ |
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Description
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Size
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Weekly # Cleaned
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Weekly # Supplied
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Weekly Rental Charge
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Quantity Ordered
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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 |
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TO DISCONTINUE THE PAYROLL
DEDUCTION
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I wish to discontinue the
payroll authorization above, effective pay period ending |
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(date) |
____________________________________
(signature) |
