Employee Payroll Deduction Form

*Legal First Name M.I.

*Legal Last Name

*Home Address

*City *State *Zip

*Last Four Digits of SSN *Employee Status

*Store Location

(NOTE: Authorized deductions will be made from gross earnings, income before taxes.)

Andy's Outreach Assistance Fund

*Contribution Type  New Change Cancellation

If this is a new or a change of existing contribution, please enter the amount you would like to contribute ($.50 minimum).     $

 I authorize Texas Roadhouse to implement the above checked payroll deduction(s).

*Initials

Authorize date: