Docstoc Legal Agreements
This Payroll Deduction Authorization Notice can be used by an employer to withhold an
amount from an employee's earnings. A payroll deduction plan offers employees a
convenient way to automatically contribute income toward an ongoing expense. Typically,
the funds are put towards insurance, healthcare or an investment account. This
authorization form contains standard provisions and it may be customized to address the
specific needs of the employer or employee. This document should be used by employers
located in Arizona that offer a payroll deduction plan to employees.
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PAYROLL DEDUCTION AUTHORIZATION
Company/Department: ____________________ [Instruction: Insert the name of Company]
Employee Name: _________________________ [Instruction: Insert the name of Employee]
Employee ID Number: _______________ [Instruction: Insert Employee ID number (if any)]
Work E-mail Address: _______________ [Instruction: Insert E-mail address of Employee]
Work Telephone Number: __________ [Instruction: Insert telephone number of Employee]
Deduction Effective Date: ____ [Month] ____ [Date], 20__
1. I hereby authorize _________________ [Instruction: Insert the name of Company] to
initiate a payroll deduction to deduct ________ ($___) [Instruction: Insert the Deduction
amount, e.g., fifty dollars ($50)] per pay period from my paycheck, effective with the pay
date of ____ [Month] ____ [Date], 20____ for any compensation that may be due to me up
to and including the total amount of any of the following:
Payroll Deduction Codes:
(Under Arizona Code, [STATUTE])
a. Uniform usage fee, if required by Company. Reasonable replacement costs of keys,
training manuals, tools, supplies, uniforms, etc. supplied to me by the Company,
which are not returned upon request.
b. Education expense reimbursed to me by employer, if termination occurs within
______ (___) [◊six (6)] months of completion of the course. Stop payment fees for
lost or destroyed payroll checks.
c. Drawer Shortage that is under my supervision and control as allowable by State
jurisdiction.
[Instruction: Please amend the above code as per your specific requirements]
2. I understand that if I am initiating or changing a payroll deduction, the deduction may not be
made if I have insufficient income in a pay period to cover this and all other required (e.g.,
taxes) and authorized deductions, and will not hold the Company liable for any deductions
not made.
3. I agree that my gross pay will be reduced by the amount of my deductions as checked and
indicated above. In the event of a deduction change during the year, the Company is
authorized to deduct the new amount from my pay.
© Copyright 2013 Docstoc Inc. registered document proprietary, copy not 2
4. I understand that this is a condition of employment and that I am obligated to pay all monies
due to the Company upon termination, resignation or failure to reappear at my place of
employment.
5. I agree that in the event a new or amended Employee Deduction Authorization Form is not
executed on or before the next year-end, this form shall be deemed to continue in force for
the next succeeding year.
____ [Month] ____ [Date], 20____
____________________________________
[Instruction: Insert the name of Employee]
__________________________________________
[Instruction: Insert the signature of Employee]
© Copyright 2013 Docstoc Inc. registered document proprietary, copy not 3
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EVEN IF DOCSTOC HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. They are for guidance and should be modified by
you or your attorney to meet your specific needs and the laws of your state or jurisdiction. Use at your own ri