PAYROLL DEDUCTION AUTHORIZATION SLIP

I, [Employee’s Name], hereby authorize [Your Company Name] to deduct the specified amounts from my salary as indicated below. This authorization is effective from January 01, 2051 and will remain in effect until December 31, 2055..

Payroll Deduction Details:

Description	Amount	Frequency
Health Insurance Premium	$150	Monthly

Terms and Conditions:

1. I understand that the amounts specified above will be deducted from my paycheck for the duration and frequency stated.

2. Any change to the deductions will require a fresh authorization from my side.

3. I have the right to revoke this authorization at any time, with a written notice of at least 30 days.
   

I have read and understood the terms and conditions pertaining to the deductions from my salary as detailed above. I agree to the specified amounts being deducted for the purposes stated.

Signature: [Employee’s Name] Date: January 15, 2051

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