| Employee Name | Date of Form | ||||
| Employee Id | SSN | Date Effective | |||
| Position Title | Department | ||||
Description of the Process
| X | Type Description | % | Amount | X | Type Description | % | Amount | |
| 401(K) | Other | |||||||
| 401(K) Loan | Other | |||||||
| Health | Other | |||||||
| Employee Loan | Other | |||||||
Additional Information
Endorsement
I understand that submitting this form approves the gross pay to be reduced even by the number of deductions listed above. If there is a deduction change during the year Payroll Deduction, my company is able to deduct a new amount. If a new form is not submitted by year’s end Payroll Deduction, that document authorizes the continuation of allowances to the next year.
| Employee Signature | Date |
| Payroll Representative | Date |
