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COMPANY NAME Payroll Deduction Authorization I, ____________________, [Insert Employee Name] hereby authorize [Insert Company Name] to withhold from my wages the total amount of $_______________ [Specify Amount] which shall be withheld at a rate of $__________ [Specify Amount] per pay period for __________ [Specify Number] numbers of pay periods for the purpose of [Explain Reason for Withholding]. I further agree that any amount owed not fully recovered by the time of my separation from the Company, either voluntarily or involuntarily, will be paid to the Company within seven days of the date of separation. I represent that this authorization is executed voluntarily and has not been made as a condition of my continued employment. ________________________________ Employee Name (Printed) ________________________________ Employee Signature ________________ Date P•A•S Associates has expertise in human resources and other areas involving employment issues. P•A•S Associates, in providing this form, does not represent that it is acting as an attorney or that it is giving any form of legal advice or legal opinion. P•A•S Associates recommends that before making any decision pertaining to human resource issues or employment issues, including the utilization of information contained on this website, the advice of legal counsel to determine the legal ramifications of the use of any such information be obtained. PAS Rev. 10/05