Faculty Association

Benevolence Fund Payroll Deduction 2014-15

(Please print and return the form to LCSC Human Resource Services)

Please deduct from my paycheck, until further notice, the following amount $_____________ per pay period and transfer this amount to the account of the Faculty Association Benevolence Committee.

Please begin deductions ASAP or on the following date __________________

Is this a new deduction?    Yes__________     No__________
Is this a modification to an existing deduction?     Yes__________     No__________
Soc. Sec. # optional, but helpful________________________________________


Signature_______________________________________________________________   Date___________________