(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________________________________________|