Voluntary salary deduction authorization form

DATE:
EFFECTIVE DATE:
EMPLOYERS NAME:
EMPLOYEE’S NAME:

TYPE OF DEDUCTIONS AMOUNT TO BE DEDUCTED FREQUENCY (PERIOD)

I hereby authorize my employer to make the above deductions from my pay in accordance with
the above terms, I understand and agree that I am responsible for satisfying the above
amounts. I further understand that these deductions shall be made after the requisite
mandatory statutory deductions have been made accordingly. I understand and agree that any
amount that is due and owing at the time of my termination, regardless of whether the
termination was voluntary or not, will be deducted from my last remuneration or any other
amounts that may be owed to me. This also authorizes my employer to retain the entire
amount of my last remuneration as a lien pending proper handing over according to company
policy.

Employee’s signature:
Date: