Payroll Deduction Authorization
Per Pay Period 1. Complete Employee Information
Employee Name________________________________________________________________________
Social Security # XXX‐XX‐___________ Employer / Client Name_________________________________________________________________ 2. Deductions
Deduction Amount For Internal Use Only Flex Spending Account (Section 125) $ ____________________ Ded. Code – Pre‐tax: ________ Ded Code – Post‐tax:________ AFLAC $____________________ Ded. Code – Pre‐tax: ________ Ded Code – Post‐tax:________ 401(k) $____________________ Ded. Code ____________________ IRA $____________________ Ded. Code ____________________ Health $____________________ Ded. Code – Pre‐tax: ________ Ded Code – Post‐tax:________ Dental $____________________ Ded. Code – Pre‐tax: ________ Ded Code – Post‐tax:________ Life Insurance $_____________________ Ded. Code – Pre‐tax: ________ Ded Code – Post‐tax:________ Other ____________________ $_____________________ Ded. Code – Pre‐tax: ________ Ded Code – Post‐tax:________ Other____________________ $_____________________ Ded. Code – Pre‐tax: ________ Ded Code – Post‐tax:________ 3. Sign, date and return completed authorization form to your payroll contact.
I authorize Employers Resource to make the following payroll deductions from each paycheck to be credited on the client payroll invoice. In the event my employment status changes (including termination of employment) any amount owed will be collected. Employee Signature__________________________________________________ Date____/____/____ OpsForm‐PayrollDeduction‐Jan2015