Fill - Free fillable CSPayrollDeductionAuthForm030618 CS Payroll Deduction Auth Form (rev.Jan2018).xlsx PDF form

______________________________________________________________________



Signature

____________________________________________________________________________

PrintName

EmployeeName(PLEASEPRINT)

EmailAddress

6/2018

Date

____________________________________________________________________________

DirectDonationOption

cashorcheck(payabletoDeAnzaCollegeClassifiedSenate )intheamountof$___________.

ReturnthisformtotheDeAnzaClassifiedSenateTreasurer mailboxintheCampusMailroom.

Division/Department

________________________________________________________________________________________

VoluntaryduescontributionstotheDeAnzaCollegeClassifiedSenatemaybeprovidedemployees

throughmonthlypayrolldeductionorbycash/personalcheck.Donationsshallbeusedtoaugmentthe

operatingexpensesoftheClassifiedSenateandtosupportactivitiesnotpermittedunderrestrictionsof

Fund114(e.g.EmployeeoftheMonth

celebrations,refreshmentsatsponsoredevents,studentsupport

funding,enhancingactivitiesfortheAnnualFHDAClassifiedProfessionalDevelopmentDay,professional

developmentactivities,donationstocampus‐basedprojects,etc.).

___EnclosedismydonationtotheDeAnzaCollegeClassifiedSenateVoluntaryDuesaccountby

EmployeeVoluntaryDonation/PayrollDeductionAuthorizationForm

Foothill‐DeAnzaCommunityCollegeDistrict(FHDACCD)

EmployeeID#

Mymonthlypayrolldeductionshallbegineffective:__________(mo.)__________(yr.)untilfurthernotice.

Date

fortheDeAnzaCollegeClassifiedSenateVoluntaryDuesaccount.

IauthorizetheFoothill‐DeAnzaCommunityCollegeDistrictto(circleone)deduct/change/cancel:

__$2___$3___$4___$5___$10Other:$____________permonth

frommypaycheckasavoluntarydeductionandtransfersuchmonies

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CSPayrollDeductionAuthForm030618 CS Payroll Deduction Auth Form (rev.Jan2018).xlsx

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