Download Payroll Deduction Authorization Form

Payroll Deduction Authorization Form
Please print clearly and provide complete and accurate information.
SECTION
Client Information
Client Company: ___________________________________________________________________________________________________
1
Authorization
I authorize WorkSmart Systems to withhold from my gross earnings the amount listed below:
Per Pay Deduction Amount: $____________________
Total Amount of Deduction: $____________________
The Total Amount of Deduction will be deducted over ________ pay periods.
Check Date to be Effective: _____________________
SECTION
Reason for Deduction: ______________________________________________________________________________________________
Wage assignment and Promissory Note are required prior to withholding from employee’s pay for any money due to Client Company.
2
Authorization for Payroll Deduction:
I authorize this deduction from my gross wages as indicated above. I understand that in the event my employment terminates for any reason,
any unpaid balance will be deducted from my final check from WorkSmart Systems. If a balance remains after my final check has been
issued, I agree to repay ______________________________________________________________________ the remaining balance.
Employee Name: _____________________________________________________
Date: _______________________________
Employee Signature: __________________________________________________
Last 4 Digits of SSN: __________________
Rev. 06.25.12
WorkSmart Systems, lnc. • 9957 Crosspoint Blvd. • Indianapolis, IN 46256 • 317.585.7870 • 877.977.9757
fax 317.863.0680 • Payroll E-mail [email protected]