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Payroll Deduction Authorization

Employee: ____________________________________________ Date:___________

Store #______________________

I have received the above listed items, for which I agree to pay full and/or one-half the cost.  I authorize KFI, LLC to withhold $____________ per paycheck (minimum $5) effective ___________ (mo, day, year) until a total of $____________ is paid.  If the entire amount has not been paid prior to termination of my employment, I authorize the balance due at that time to be deducted from my final paycheck.  Each time a deduction for uniform costs is made from my paycheck, I agree to sign a authorization approving the deduction.  I understand that I am signing such a deduction authorization freely and voluntarily, without fear of retaliation or termination of employment, if I fail to sign.  I further understand that the paycheck deduction is being done at my request, as a courtesy provided to me by the Company.

Employee Signature

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