P
P
A
A
Y
Y
R
R
O
O
L
L
L
L
D
D
E
E
D
D
U
U
C
C
T
T
I
I
O
O
N
N
C
C
A
A
N
N
C
C
E
E
L
L
L
L
A
A
T
T
I
I
O
O
N
N
F
F
O
O
R
R
M
M
TO: PAYROLL AND BENEFITS DIVISION
FROM: EMPLOYEE NAME (PRINT LEGAL NAME):
_________________________________________________
EMPLOYEE ID#:__________________________________
DEPARTMENT: ___________________________________
CONTACT PHONE NUMBER:_______________________
CANCEL THE FOLLOWING DEDUCTION(S) FROM MY PAYCHECK, EFFECTIVE
IMMEDIATELY *(See below Payroll deadline note)*
NAME OF DEDUCTION(S)_____________________________________
______________________________________
______________________________________
_______________________________________
PARKING DEDUCTION: Cancellation MUST include authorizing Parking Coordinator signature below:
General Services Dept, Parking Level of Govt. Service Center, (404) 612-5900
Signature:_______________________________________ Date:___________
FITNESS DEDUCTION: Cancellation MUST include authorizing Fitness Coordinator signature below:
Donnie Coley, Fitness Center, 4
th
Floor of Govt. Service Center (404) 612-7083
Signature:______________________________________ Date:___________
* Payroll Deadline: This form must be received in the Finance Department by 12 noon on the Friday before
pay day for the change to reflect on the next upcoming pay day.
Completed payroll documents received after the payroll deadline will be processed for the next pay period.
EMPLOYEE SIGNATURE___________________________________________ DATE________________
EMPLOYEE BENEFITS DIVISION
141 PRYOR STREET, S.W., SUITE 7001
ATLANTA, GEORGIA 30303
TELEPHONE (404) 612 -7605
EMAIL: payrollunit@fultoncountyga.gov
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