Date:

Name of Company:

Name of Supervisor:

Address of Company:

Dear (name of supervisor):

This letter confirms that I, (name of employee), authorize XYZ Company to deduct the sum of (specify) from my regular gross earnings each payroll period beginning on (date), for (specify nature of deductions).

I authorize you to make this deduction automatically until (specify: until my indebtedness to name of recipient of deduction has been fully satisfied, until I revoke this authorization in writing, or until my employment with XYZ Company ceases).

If this indebtedness remains unsatisfied upon my termination or resignation, then I agree to (specify).

Thank you for your assistance in this regard.

Very truly yours,

(Name of Employee)

(Social Security #)

MANAGEMENT AUTHORIZATION

Request Approved:

Effective Date:

Request Denied: (Specify Reason)

By:

Title:

Comments:

Date: