Authorization for Payroll Deduction
Last Name: _____________________________ First Name: ____________________________
Deduction Information:
What would you like to do?
Initiate a Deduction Terminate a Deduction Change a Deduction
Frequency of Deduction: One Time Bi-Weekly
Amount to be Deducted: ______________ Goal Amount (if applicable): _____________
Pay Period Beginning: ______________ Pay Period Ending:______________
This deduction is payable to:
_________________________________________________________________________
Name
_________________________________________________________________________
Mailing Address
_________________________________________________________________________
City/State/Zip
_________________________________________________________________________
Phone Number
_________________________________________________________________________
Account #
_________________________________________________________________________
Contact Name
Employee Authorization:
1. I hereby authorize LPTC Payroll office to initiate, terminate, or change a payroll deduction, as
appropriate, based on my selection above.
2. I understand that once the payroll deduction is in place I can only terminate or change the dollar
amount.
3. I understand my signature below also releases LPTC and any employees thereof from any liability
relating to this authorized payroll deduction.
Employee Signature: ______________________________________________ Date: ________________
Payroll Signature:_________________________________________________ Date:_________________
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