Payroll Deduction Form

Employee NameDate of Form
Employee IdSSNDate Effective
Position TitleDepartment

Description of the Process

XType Description%AmountXType Description%Amount
401(K) LoanOther
Employee LoanOther


Additional Information



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 SignatureDate


Payroll RepresentativeDate