Payroll Deduction Authorization Form printable pdf download

PAYROLL DEDUCTION AUTHORIZATION FORM

Students may choose to dedicate all or part of their bi-weekly work-study earnings paycheck to

their tuition account. The amount pledged toward the account will be protected from late fees

while the student is paying these funds to her account.

Pledged amounts should be

reasonable amounts that the student is expecting to earn. Pledged amounts not earned by

the end of the semester may be owed by the student.

Pledged amounts must exceed

$100/semester. There are two options available. (Please note: Deductions will continue if you

earn over Interterm.)

I, ____________________________________________ (name, print clearly),

ID # _________________________, choose:

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OPTION 1 - FULL DEDUCTION

Please deduct my entire work-study earnings and pay them toward my tuition account each

payroll until I reach a total of $___________.

____

Check here if you'd like it divided evenly by semester

____

Check here if you'd prefer $________ for the fall and $______for the spring

*Please use dollar amounts. Percentages will not be accepted.

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OPTION 2 - PARTIAL DEDUCTION

Please deduct only part of my work-study earnings and pay them toward my tuition account each

payroll until I reach a total of $______________.

Deduct $____________ per check.

____

Check here if you'd like it divided evenly by semester

____

Check here if you'd prefer $________ for the fall and $_______ for the spring

*Please use dollar amounts. Percentages will not be accepted.

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_____ Please CANCEL my payroll deduction authorization.

For any of the above designations, sign your approval here:

Signed ___________________________________ Date ___________________

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For Office Use Only:

Fall Memo Amount $__________

Spring Memo Amount $__________

Staff Initals: ________ Date:________

Staff Initials: ________ Date:________

Copy to Payroll: _______

Payroll Deduction Authorization Form