LCSC | Faculty Benevolence Fund Payroll Deduction

Faculty Benevolence Fund Payroll Deduction

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
Name _______________________________	Date _______________________________
Soc. Sec. # optional but helpful _______________________________	Signature _______________________________

PLEASE RETURN THIS FORM TO HUMAN RESOURCES

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