Payroll Deduction Authorization Form

Payroll Deduction Authorization Form Complete this form to initiate, terminate, or change a payroll deduction, and submit the completed form to your payroll office. A separate form must be completed for each transaction. Team Member Name:____________________________ Team Member Location:___________________________ Check the appropriate box. Initiate payroll deduction

Terminate payroll deduction

Change payroll deduction

I hereby authorize Viafield to deduct $___________ from each bi-weekly paycheck effective_______________ through _________________. The total sum of all deductions shall equal $________________ . This deduction is for________________________________________________________________________ . I understand that if my employment with Viafield terminates for any reason prior to my repayment, I hereby authorize Viafield to withhold the remaining balance from my final paycheck. In the event that my final paycheck does not cover the entire unpaid balance, I agree to issue a separate check for the remaining amount, as appropriate. Agreed To and Accepted: _________________________________________________ Team Member Signature:

_____________________________ Date:

_________________________________________________ Senior Team Leader Signature:

_____________________________ Date:

Please send completed form to Human Resources at [email protected] or Payroll at [email protected]