PAYROLL DEDUCTION AUTHORIZATION - TYPE A
I authorize __________________
To deduct $ _________________ from my gross earnings
each payroll period beginning _____________________.
IN PAYMENT FOR: AMOUNT
[ ] Credit
Union _________.___
[ ] Employee
Savings Plan _________.___
[ ] 401 K
Plan _________.___
[ ] Union
Dues _________.___
[ ]
_________________ _________.___
Total $_________.___
Signature __________________________ Date
________________
Print Name ________________________
Social Security # ______-______-______
Please keep a copy of this for your records.
