Contra Costa Community College District
Payroll Deduction Authorization Form
Employee Name:______________________________________________________________
Employee ID/SSN: ____________________________________________________________
Phone Number: ________________________________________________________
Please check one of the following:
New Deduction:_______ Terminate Deduction: ________ Change Deduction: _______
Organization or TSA Company_____________________________________________________
If this is a new deduction, please write your confirmation # :____________________________
If your TSA Company is CalSTRS/CalPERS, please check one: 403b 457
Current Amount/Percentage:_______________ New Amount/Percentage:_________________
I want this change effective on my (please write paycheck date)_________________ paycheck
I hereby authorize Contra Costa Community College District (CCCCD) to initiate a payroll deduction,
terminate a payroll deduction, or change a payroll deduction, as appropriate based on the selection I have
checked above.
I understand that if I am initiating or changing a payroll deduction, the deduction may not be made if I
have insufficient income in a pay period to cover this and other required and authorized deductions, and
will not hold CCCCD liable for any deductions not made.
I understand that if I am terminating a payroll deduction, the deduction may still be taken during the
current payroll due to the time needed to process the termination, and will not hold CCCCD liable for any
deductions made.
I understand that I am changing a payroll deduction; the change may not take effect during the current
payroll cycle due to the time needed to process the change.
I agree that this deduction shall be made each month until changed or cancelled by submission of a Payroll
Deduction Authorization Form.
I understand that for TSA deductions, I need to establish an account with the TSA
Company for CCCCD’s group plan before I initiate a payroll deduction. A list of
vendors and CCCCD plan group numbers can be found on the District’s website
under Deferred Compensation. Hourly employees are not eligible for TSA’s.
CCCCD shall have no liability for any loss suffered by the Employee with regard to his/her selected
company; or for funds transmitted in the manner authorized by its Tax Sheltered and Investment Programs
and/or a 457 CalPERS plan. All deductions shall be made in accordance with Education Code Sections
22810, 22811and 22812; Internal Revenue Code of 1954 as amended; Section 17512 of the California
Revenue and Taxation Code and of the Plan adopted by the Governing Board of CCCCD.
Employee Signature:__________________________________
FOR PAYROLL USE ONLY
Entered By ___________________ Date: ________________ Deduction Code: _______
or
