I, business name hereby authorize to deduct the sum of amount from my earnings at the rate of $ amount per pay period for specify numberpay periods for the purpose of [explain reason for withholding]. I further agree that, unless prohibited by federal or state minimum wage law, the company may withhold the remaining amount owed from my last pay if my employment terminates, either willingly or involuntarily, prior to the full payback of the entire sum set forth above. I represent that I am providing this authorization willingly and not as a condition of my ongoing employment.