Automatic Payroll Deduction Form - Kodiak Building Partners

AUTHORIZATION FOR AUTOMATIC PAYROLL DEDUCTION FOR EMPLOYEE ASSISTANCE FUND

100% OF ALL CONTRIBUTIONS WILL BE MATCHED BY KODIAK

I give authorization to Kodiak Building Partners, its respective subsidiaries, and its affiliates, to deduct contributions to the Employee Assistance Fund, which is a part of the Kodiak Building Partners Foundation.

I understand that this is a voluntary after-tax deduction that can be taken as a deduction when filing my individual tax return and that my deduction will be sent directly to the Employee Assistance Fund. This deduction can be stopped at any time by checking Cancel Payroll Deduction and submitting this form.

At no time will a verbal authorization be accepted either to change or stop the amount of the voluntary deduction. If changes need to be made to the amount or duration of the deduction, the employee must complete and sign a new form authorizing the change or canceling this approval.

I authorize one of the following deductions:

RECURRING
Recurring Payroll Deduction Every Pay Period

ONE-TIME
One-Time Payroll Deduction for a Single Pay Period

CANCEL
Cancel Payroll Deduction

Recurring Deduction Amount ($)

One-Time Deduction Amount ($)

Kodiak Company you are affiliated with

First Name

Last Name

Title

Last 4 Digits of SS#

SIGNATURE

DATE

Form

Assistance Request Form

AUTHORIZATION FOR AUTOMATIC PAYROLL DEDUCTION FOR EMPLOYEE ASSISTANCE FUND