Fillable Printable Payroll Deduction Sample Form

Payroll Deduction Sample Form

AUTHORIZATION

FOR VOLUNTARY PAYROLL DEDUCTION

Allowed under RSA 275:48 I

hereby authorize

(Print employee’s name)

to deduct from my wages

(Employer)

for:

(reason for the deduction)

the sum of $

, beginning

and ending

(Amount)

(Date) (Date)

until the total amount of $

has been deducted.

(Amount)

I am authorizing this voluntary deduction as specified in RSA 275:48 I.

In the event my employment ends for any reason before the final deduction is made, the

entire balance may

(X) or may not

(X) be deducted from my final wages.

(Employee’s Signature)

(Date signed)