COMPANY NAME

REQUEST FOR DEDUCTION

To whom it may concern:

I am requesting the company to deduct from my salary the

amount of __________________ as payment for the following:

Item (s) Amount

______________________________ P______________

______________________________ ______________

______________________________ ______________

______________________________ ______________

______________________________ ______________

That the deduction per pay period is

I understand that the above mentioned deduction(s) is/are NOT

required by the Company and I am requesting the deduction
voluntarily and willingly, with my full knowledge and consent.

I have signed this form without any threat, force, or violation of

any kind or form.

Name: __________________________
(Signature over printed name)

Noted by: _______________________