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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]