Third-Party Payroll Authorization Form
Authorize a third party to handle payroll-related actions on your behalf. Please review and complete all sections of the Third-Party Payroll Authorization Form.
Employee Full Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Employee Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employer/Company Name
*
Third Party Organization Name
*
Type of Payroll Actions Authorized
*
Payroll processing
Tax filings
Direct deposit setup
Payroll record updates
Other
Authorization Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorization End Date (if applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Instructions or Limitations (optional)
Employee Signature
*
Submit
Submit
Should be Empty: