Authorization to Withhold Campus Card Declining Balance Deposit Amounts from Payroll

Please complete, print, sign, and submit this form to the Card Office (Starbuck Center) or the Payroll Office (Barrett Center)

PLEASE COMPLETE ALL SECTIONS
Name
Type of authorization First-time request.
Change my current deduction amount.
Stop my current deduction agreement.
Bi-Weekly payroll Deduction Amount (minimum is $5 per pay period)
Effective date for this change
Signature
Date of Signature

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