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Hanover Township
Employee's Request for Additional Withholdings from Paycheck

Township Employees that wish to add additional withholdings to their Health Savings Account; Equi-Vest, (Retirment Savings); IMRF, (Additional Retirment Savings); or to change withholding information on your Federal W-4 or Illinois W-4, should use this form to request a change in withholding levels.

Employee Name:
Contact Number:
Employee Email:
Deduction Effective Date:
Payroll Deductions:
Health Savings Account
Equi-Vest (Retirement)
IMRF (Retirment)
Employee Loans
For Health Savings Accounts, please provide the following information:
Banking Institution Name:
Banking Insitution Routing #:
Banking Institution Account #:

I agree that my gross pay will be reduced by the amount of my deduction as checked and indicated above.  In the event of a deduction change during the year, my employer is authorized to deduct the new amount from my pay.

In the event a new Employee Deduction Authorization Form is not executed on or before the next year-end, this form shall be deemed to continue in force for the next succeeding year.

Human Resources may be in contact with you for additional documentation.

Employee Signature: Date:
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