Rev 09/11
Louisiana State University
Office of Accounting Services
Payroll
204 Thomas Boyd Hall
ACADEMIC EMPLOYEE REQUEST FOR TWELVE CHECKS AS249
Employee ___________________________ __________________________________ ________
Last First MI
LSU ID ___________________________
Department
_________________________________________________________________
Whereas, my name is listed in the University budget to have my salary paid to me on an academic basis, or in nine
payments, I hereby request a change to an academic withheld basis to facilitate receipt of twelve checks.
I understand that my salary will be paid over nine months with approximately 25% of the net check withheld as a
payroll deduction. During each of the summer months - June, July and August - I understand that I will receive a check
for one-third of the amount accumulated in the withheld account. While I will receive a check every month, I
understand that my salary is paid over nine months.
I further understand that all of my deductions will be withheld over nine months - Federal and State withholding,
insurance payments, retirement and annuity contributions, Credit Union deductions, etc. I understand that it is my
responsibility when establishing a payroll deduction that it is for an amount that will satisfy the total amount due with
deductions over nine months.
The first check will be issued on the last working day of September and the other checks will be issued on the last
working day of each month thereafter. I understand this is a change from the normal academic payday on the
twenty-first of the month to the last working day of the month. This authorization is to continue in effect each year
unless I notify you in writing prior to the first academic check of the year.
It is understood that should I request withdrawal of my accumulated withheld account during the year that I will not be
eligible to continue receiving payments on an academic withheld twelve month basis thereafter, but instead will change
to an academic basis, receiving nine payments.
If it becomes necessary that I go on Leave Without Pay (LWOP), it is understood that I must switch back to an
academic pay basis.
Should I resign my position, it is understood that the full amount of my accumulated withheld account will be paid to me
at that time.
Signature _______________________________________ Date _________________________
Note: In order for this request to be applicable for the current year, it must be in effect prior to the first academic
check of the year. Completed form should be turned in to your department HR representative.
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FOR ACCOUNTING SERVICES USE ONLY
Form # _____________________ Effective Date ______________________
