Payroll Deduction Authorization
Employee: ____________________________________________ Date:___________
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.