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Payroll Deduction Authorization Form


Employee Information:

  • Employee Name:
  • Employee ID:
  • Department:
  • Position:

Overpayment Details:

  • Description of Overpayment: (Brief description of the overpaid expense)
  • Total Amount of Overpayment:
  • Date of Overpayment:

Deduction Details:

Amount to be Deducted per Pay Period: (This can be a fixed amount or a percentage of the pay)
Start Date of Deduction:
End Date of Deduction: (or number of pay periods)
Total Number of Deductions:

Authorization Statement:

A brief paragraph stating that the employee authorizes the specified deductions from their payroll to repay the overpaid expenses. It should be clarified that this deduction is in accordance with company policies.

Acknowledgment and Consent:

Employee’s Signature:

HR or Manager’s Signature:

Additional Notes:

(Space for any additional remarks or notes related to the payroll deduction).