Payroll Deduction Authorization Form

Name:  *(required)

Phone:  *(required)

Address:  *(required)

Email:  *(required)

City:  *(required)

State:  *(required)

Zip:  *(required)

TUID/Username:  *(required)

Employee #:  *(required)

Department:  *(required)

Mail Code:  *(required)

Payroll Deduction:

Create a New payroll deduction of    $    per pay period.

Change an existing payroll deduction from    $    to    $   .

This deduction is designated for:

Foundation Donation Designated for Student Scholarships

Foundation Donation Designated for Program Fund (specify fund)  

Foundation Donation Other (please specify)  

Employee Development Fund (EDF) Membership (min. $1 per pay period)

Special Instructions or Comments:

Authorization:

By typing my name in the box, I am submitting an electronic signature authorizing the transaction listed above.


Type in Name to Authorize  *(required)


Date  *(required)

* Denotes a required field

Any questions, contact Beth Vanderlip 483-1986, email: vanderle@lcc.edu.