I authorize [company name] to withhold from my wages the total amount of $ [amount] which shall be withheld at a rate of $ [amount] per pay period for [number] of pay periods for the purpose of [explain the reason for withholding].
I further agree that in the event my employment shall terminate, either voluntarily or involuntarily, prior to the full repayment of the total amount set forth above, the company may withhold the remaining amount owed from my final pay, except to the extent prohibited by federal or state law.
I represent that this authorization is executed voluntarily and has not been made as a condition of my continued employment.
Employee name (printed): ________________________________________
Employee signature: ____________________________________________
Date: ________________________________________________________
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