Payroll Deduction Authorization Form
This form needs to be completed and sent to your employer's human resource department.
Email address *
Passenger Name (Name of Employee) *
Your answer
Passenger Phone Number *
111-111-1111
Your answer
Employer Name *
Your answer
Employer Email Address *
Your answer
Cost Per Ride - $20.00
The cost per ride is $20 (twenty dollars). A ride is considered to and from work. However, in the event that I leave my shift early or cancel the ride, additional charges may apply. Additional charges shall be discussed with Patterson personnel and charged to passenger.
Please Select Correct Cost Per Ride *
This confirms you understand the cost per ride
Your answer
Transportation Clause
I hereby authorize my employer (listed above) to deduct above amount from pay check in accordance with the above terms. I understand and agree that I am responsible for satisfying the above amounts. I understand and agree that any amount that is due and owing at the time of my termination, regardless of whether my termination was voluntary or not, will be deducted from my last paycheck. This authorizes my employer to release the payment to Patterson Transportation before distributing my last payment. I also acknowledge that all charges related to transportation will be directed to the transportation company as my employer (listed above) is only a third party granted permission to automatically deduct wages. I understand that this is a voluntary program and not mandated to be an employee of my employer (listed above) but a service offered by a third party. My employer is not liable for any discrepancies pertaining to transportation charges from said company and employee. I also understand that I may cancel this agreement at any time by submitting to Patterson Transportation and my employer (listed above) a cancelation request in writing. I also understand that typing my name, date of birth, last four of my social, and the date constitutes my acknowledgement of this agreement and it will be deemed as a handwritten signature.
Employee Signature *
Your answer
Today's Date *
MM
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DD
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YYYY
Date of Birth *
MM
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DD
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YYYY
Last Four of SSN *
Your answer
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