AUTHORIZATION FOR STATE OF KANSAS
ADDITIONAL WITHHOLDING TAX DEDUCTION
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EMPLOYEE INFORMATION
Name:
Social Security No.___________________________
SECTION A: AUTHORIZATION
EFFECTIVE DATE: _________________________
STATE ADDITIONAL WITHHOLDING TAX AMOUNT: _________________________________________
I hereby authorize Rhatigan Student Center to make regular payroll deductions from my earnings for the
Amount certified above. This authorization is to remain in effect until cancelled by me in writing or
termination of my employment.
___________________________________
EMPLOYEE SIGNATURE DATE
SECTION B: CANCELLATION
EFFECTIVE DATE: _______________________
I hereby cancel the authorization for State additional withholding tax deductions from my earnings.
_______________________________________________________________________________
EMPLOYEE SIGNATURE DATE
AUTHORIZATION KS ADDITIONAL WITHHOLD TAX
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