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
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
Signature __________________________ Date
Print Name ________________________
Social Security # _____-_____-_____
Please keep a copy of this for your records.