Fillable Oakwood Healthcare Inc. Employee Payroll Deduction Authorization Form printable pdf download

OAKWOOD HEALTHCARE INC.

EMPLOYEE PAYROLL DEDUCTION AUTHORIZATION FORM

Employee Name:

_____________________________

Employee ID: __________________

Employees Home Business Unit & Department: _______________________________________

Work Phone: __________________________ Home Phone: ___________________________

Work Email: ___________________________ Home Email: ___________________________

Employee payroll deduction enables you, as an Oakwood employee, to use your I.D. badge to make

purchases at any participating Oakwood retail operations. You may make purchases up to the limit

referenced in the Employee Authorized Payroll Deduction Policy each pay period. This limit is for all

participating operations combined. The amount of the purchase is then deducted directly from your

next paycheck.

Activate My Employee Payroll Deduction Authorization – I authorize Oakwood to deduct

from my paycheck the total amount of all purchases each pay period. If I purchase over the

limit, the total amount purchased will be deducted. If the total amount cannot be deducted

from my next paycheck, it will be deducted from subsequent paychecks and my authorization

will be turned off until it is paid in full.

I understand that based on vendor limitations, separate limits will be enforced at each retail

operation. These limits may change, as needed, at any time. Refer to the limits posted on the

Payroll Oaknet page under: Retail Operations Limits.

I agree that I am solely responsible for any purchases made with my badge. If I lose my

badge, I will immediately notify Human Resources so the badge can be inactivated and

reissued.

I agree that if my employment with Oakwood terminates for any reason, the full amount of the

unpaid balance of my charges shall become immediately due and payable and will be

deducted from my final paycheck. If my final paycheck does not cover the unpaid balance, I

will pay directly to Oakwood Healthcare, Inc., Payroll Department within 10 days of my

termination date.

I understand that this privilege is only extended to full-time and part-time employees. Should I

transfer to a contingent status, this privilege will be revoked. I would need to re-enroll should I

go back to a full-time or part-time status in the future.

I understand that this privilege will be revoked should I go on a leave of absence for any

reason (personal, medical, family, etc.) or are put in a layoff status. I would need to re-enroll

when I return from my leave of absence or return from layoff.

I understand that this privilege is extended as a courtesy of Oakwood, and it is assumed that I

will exercise sound judgment in its use. In the event that I abuse this policy, then this privilege

may be revoked.

Inactivate My Employee Payroll Deduction Authorization – I authorize Oakwood to cancel

my Employee Payroll Deduction enrollment. I understand I am still responsible to pay the

balance of my charges. I further understand that I will no longer be permitted to incur charges.

Employee Signature: _____________________________________ Date: _________________

Forward this completed form to the Payroll Department.

Payroll Fax's: 313.791.4781 or 313.792.7139

Oakwood Healthcare Inc. Employee Payroll Deduction Authorization Form