Payroll deduction authorization template (US)

Payroll Deduction Authorization

Employee name: Employee Name

Employee ID: Employee ID

Department: Department

Authorization

I voluntarily authorize Employer Name to deduct the following from my wages:

• Purpose of deduction: Purpose, such as Repayment of a Pay Advance, Purchase of Company Equipment, Uniforms, or a Voluntary Contribution

• Total amount: $Total Amount

• Amount per paycheck: $Amount per Paycheck

• Starting with the paycheck dated: First Deduction Date

• Number of paychecks: Number of Deductions

Final Paycheck

If my employment ends before the total is repaid, I Do or Do Not authorize Employer to deduct the remaining balance from my final paycheck, only as far as federal and state law allow.

Legal Limits

Employer will make these deductions only as federal and state wage laws allow. No deduction will reduce my pay below the minimum wage for the hours worked, or cut into overtime pay owed to me if I am non-exempt. Some states require separate written authorization for each deduction, or do not allow certain deductions; this authorization applies only as far as the law of my work state allows.

Cancellation

I may cancel this authorization for future deductions by written notice to Payroll Contact, except that a deduction to repay money I have already received may continue as far as the law allows. Cancelling the authorization does not cancel any debt I owe.

Acknowledgment

I have read and understand this authorization, I sign it voluntarily, and I have received a copy.

Employee signature: Employee Signature

Date: Employee Signing Date

Received by payroll: Payroll Representative Name and Signature

Date: Payroll Receipt Date