DEDUCTION AUTHORIZATION Company Name

Employee Information Social Security Number

First Name

Middle Initial .

Last Name

Dept Position

Type of Deduction

Insurance Pay Period Deduction Other

Pay Period Deduction

Group Medical $ Uniform $ Pre-Tax After Tax

Dental $ Tools $ Pre-Tax After Tax

Vision $ Equipment $ Pre-Tax After Tax

Short Term Disability $ Advance Repayment $

Long Term Disability $ Loan Repayment $

Life $ Purchase

401k $ Christmas Club $ %

Other $ Miscellaneous $

Notice to Employees All deduction amounts are listed per pay period and, where applicable the total amount of the obligation is noted. Where relevant The Employee Management Team (EMT) will remit the amount to the Client Company listed above on your behalf for payment of the obligation. The withholding will begin immediately and continue until the obligation is paid in full. In the event of the termination of your employment for any reason, the entire amount due and owing becomes immediately due and payable and will be deducted from your paycheck(s). To revoke this authorization you must submit the revocation in writing to EMT. The revocation will become effective within 14 days after receipt.

Agreement & Authorization

I authorize The Employee Management Team at their discretion, to withdraw the above funds from my payroll and/or adjust my payroll deductions. I understand and agree that deductions will begin immediately and in the event of Termination of my employment for any reason, the entire amount due and owing becomes payable and will be deducted from my final paycheck.

Employee Signature Date

HR Form 004- Deduction Authorization - 9/24/14

Client Company ___________________