Payroll Deduction Form

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



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.


Employee Signature Date


Payroll Representative Date