Payroll Deduction Authorization/cancellation Form

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PPSD u se o nly
CITY AND COUNTY OF SAN FRANCISCO
/
PAYROLL
PERSONNEL SERVICES DIVISION
Payroll Deduction Authorization/Cancellation Form
If no response after two pay periods, call PPSD. Do not resubmit.
EFFECTIVE DATE
NEW AUTHORIZATION
CHANGE AUTHORIZATION
CANCELLATION
MM
DD
YY
/
/
RECORD
EMPLOYEE NAME
.
.
DEPT
ID
EMPLOYEE ID
DEPT
NAME
JOB CLASS
#
.
.
LAST
FIRST
M
I
OR
$_____________
_________%_
$___________
BIWEEKLY DEDUCTION AMOUNT
PERCENT
GOAL AMOUNT
3-DIGIT ALPHA
3-DIGIT #
—
DEDUCTION CODE
DEDUCTION NAME
NEW AUTHORIZATION
CHANGE AUTHORIZATION
I hereby authorize the Controller of City and County of San Francisco to withold from each of my salary warrants
the deduction amount stated above and to transmit said sum to the organization named above.
I consent to the adjustment of such deduction (1) to conform to future pay period change or (2) reflect any change
in union dues of which the Controller may be advised by the organization. This authorization shall be in full force
and effect until revoked by the undersigned or by the organization.
Any discrepancies in my voluntary deductions as reported on my pay stub must be reported by me in writing to
th
PPSD, One South Van Ness Ave., 8
floor, San Francisco, CA 94103 within 30 days after the occurrence.
_________________________________
_________________________
’
SIGNATURE OF EMPLOYEE
TODAY
S DATE
-
,
CANCELLATION
SIGN AND DATE THIS SECTION AND FORWARD TO YOUR UNION
IF APPROPRIATE
I hearby request the Controller of the City and County of San Francisco to cancel the salary deduction named
above. I understand that the ability to cancel my payroll deduction may be subject to restrictions and/or
requirements stated in my Memorandum of Understanding and that it is my responsibility to ensure all
necessary requirements have been met before submitting this request.
_________________________________
_________________________
’
SIGNATURE OF EMPLOYEE
TODAY
S DATE
UNION / AGENCY / DEPARTMENT USE ONLY
PHONE
AUTHORIZED BY
DATE
___________________________________________
____________
______________
SIGNATURE
DO NOT WRITE BELOW THIS LINE
PPSD USE ONLY
_____________________
____________________
____________________
PREPARED BY
PHONE
DATE
________________________
____________________
____________________
KEYED BY
PHONE
DATE
K:\W
F
\P
_D
_F
2016.
07/18/2016
EBSITE
ORMS
AYROLL
EDUCTION
ORM
DOCX

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