|Employee Name||Date of Form|
|Employee Id||SSN||Date Effective|
Description of the Process
|X||Type Description||%||Amount||X||Type Description||%||Amount|
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, my company is able to deduct a new amount. If a new form is not submitted by year’s end, that document authorizes the continuation of allowances to the next year.