Page 68 - City of Farmington Administrative Regulations

ATTACHMENT C
64
AUTHORIZATION Of PAYROLL DEDUCTION,
FOR SAFETY SHOES'

t understand that the City of Farmington, in assisting me to purchase safety shoes, will
contribute fifty percent (50%) of the cost of the shoes up to $75.00. As an example, I understand
that if I select a pair of safety shoes costing $100.00, the City of Farmington will contribute
$50.00; further, if I select a pair of safety shoes costing $160.00, the City of Farmington will
contribute only $75.00.

I authorize the City of Farmington to withhold from my paycheck(s) as a payroll deduction the
total amount of $ divided among three consecutive pay periods in the
following manner:

First
Pay Date of: ---------

Second

Pay Date of: ---------

Third
Pay Date of: ---- -----

I understand that if I terminate my employment, either voluntarily or involuntarily, within 180
days after I receive these safety shoes, I will be required to reimburse all or a portion of the
City's share of the cost of the safety shoes.

Employee Signature

Date

Employee Printed Name

DepartmenUDivision Head signature

If the total amount cannot be evenly divided, the larger amount must be taken first with the
smaller remaining amount taken last.