Employee Portal

Payroll Deduction Form

Employee Name(Required)

First Last

Employee Email(Required)

Employee ID Number(Required)

I have purchased the following:(Required)

Quantity

Item Description

Single Item Cost

Total Cost

Is your Payroll Deduct for any of the following:(Required)

How much would you like to be witheld from each paycheck(Required)

The amount withheld from each paycheck must be at least $10 and not exceed 4 pay periods.

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