EMPLOYEE PAYROLL DEDUCTION AGREEMENT - ?· EMPLOYEE PAYROLL DEDUCTION AGREEMENT EMPLOYEE INFORMATION…

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  • EMPLOYEE PAYROLL DEDUCTION AGREEMENT

    EMPLOYEE INFORMATION (Complete all fields.) Employee Name: First Middle Last

    Last 4 Digits of Soc. Sec. No.:

    Effective Date:

    Client Company Name: Client No.:

    I, , approve for Employer Flexible to make deductions as indicated below from my wages/salary payable each pay period. I also agree that if I terminate employment prior to my final payment for this expense, I authorize Employer Flexible to deduct any unpaid expense amount from any wages/salary owed to me at the time of termination of employment.

    Deduction Reason Check one

    Effective Date (Beginning Pay Period) mm/dd/yyyy

    Amount deducted per

    pay period $ or %

    Total Amount to be deducted

    401K Plan (not administered by employer flexible) O New O Change $ . ROTH Plan (not administered by employer flexible) O New O Change $ . Payroll Advanced that was paid through Employer Flexible O New O Change $ . Payroll Advanced that was NOT paid through Employer Flexible O New O Change $ . Employee Deduction for:

    O New O Change $ . Employee Deduction for:

    O New O Change $ . Changes To The Above Deduction Directions Must Be Submitted On A New Form.

    Employee Deductions That Stop Must Be Initialed By A Supervisor.

    Approved by:

    Employee Signature Date

    Supervisor/ HR Rep Signature Date

    Payroll Entry Date

    Please keep a copy of this document for your records.

    Employer Flexible HR Copyright 2013, All rights reserved

    9.0.0.2.20101008.1.734229

    TextField1: CheckBox1: 0

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