PAYROLL DEDUCTION AUTHORIZATION

The undersigned hereby authorizes_______________________________ (name of company) to deduct a total of $_______________ from my gross earnings each payroll period beginning _________________ (date), as follows:

In payment for:         Amount:

___ Credit Union
$_________._____
___ Employee Savings Plan $_________._____
___ 401(k) Plan $_________._____
___ Union Dues  $_________._____
___ _____________________________ $_________._____
___ _____________________________ $_________._____
___ _____________________________ $_________._____
___ _____________________________ $_________._____

Total
$_________._____

_______________________________________
Signature

________________
Date

_______________________________________
Printed Name

_______________________________________
Social Security Number

NOTE: Please keep a copy of this form for your records.
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