PAYROLL DEDUCTION AUTHORIZATION FORM

Employee Name:	___________________SSN:  _____________

Deduction Effective Date:	___________________

Payroll Deductions:

•	401(k) 	  		% or $______________

•	401(k) Loan			        $______________

•	Health				        $______________

•	Employee Loans		        $______________

•	Other _________________         $______________

I agree that my gross pay will be reduced by the amount of my deduction as checked and indicated above.  In the event of a deduction change during the year, my employer is authorized to deduct the new amount from my pay.

In the event a new 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.

Employee Signature:	_____________________ Date:___________