PAYROLL DEDUCTION AUTHORIZATION - TYPE B

THE UNDERSIGNED DOES HEREBY AUTHORIZE ________________________ (hereinafter referred to as Company)

To deduct the amount of $ __________ (dollars)

From his/her gross earnings each payroll period beginning ________________________

In payment for ________________________________________________________

As per agreement, these deductions will continue until the above obligation is paid in full or until employment with said company is terminated for any reason. Should employment be terminated prior to the payment in full of this obligation, the undersigned agrees to pay the balance owed on or before the termination date.

Signature __________________________ Date ___________________

Print Name ________________________

Social Security # _____-_____-_____

Please keep a copy of this for your records.