Updated on 6/3/2019
PAYROLL DEDUCTION
CAFETERIA MEAL PLAN
DEDUCTION DESCRIPTION
X
PAYROLL DEDUCTION
DATE
PAYROLL DEADLINE
MEAL MAXIMUM PER
EFFECTIVE TERM
EFFECTIVE TERM AMOUNT
15
TH
of the Month
3
rd
of the Month
20 16
th
15
th
of the following month $125-
End of the Month
10
th
of the Month
20 1
st
31
st
of the following month $125-
TERMS
DEDUCTIONS CAN BEGIN AS EARLY AS THE NEXT AVAILABLE PAYROLL CYCLE WHEN AUTHORIZATION FORMS ARE RECEIVED
ON OR BEFORE THE PAYROLL DEADLINE DATE LISTED ABOVE. MEAL PLANS ARE EFFECTIVE DURING THE EFFECTIVE TERM
FOLLOWING THE INDIVIDUAL’S PAYROLL DEDUCTION. PLANS INCLUDE THE TRADITIONAL “MEAL DEAL OPTION (MAIN + SIDE
DISHES, DRINK, & CHOICE OF SOUP, SALAD OR DESSERT). INDIVIDUAL MAY UTILIZE THEIR MEAL PLANS DURING ANY MEAL
PERIOD (BREAKFAST, LUNCH & DINNER) TO THE MAXIMUM ALLOTTED MEALS PER EFFECTIVE TERM. MEALS ARE NOT
TRANSFERABLE BETWEEN EFFECTIVE TERMS NOR BETWEEN OTHER INDIVIDUALS. INDIVIDUAL MAY CANCEL AT ANY TIME VIA
WRITTEN NOTICE AUTHORIZING THE CANCELLATION. CANCELLATIONS RECEIVED AFTER THE PAYROLL DEADLINE MAY NOT TAKE
EFFECT UNTIL THE FOLLOWING PAYROLL CYCLE.
AUTHORIZATION
I UNDERSTAND THAT THIS FORM AUTHORIZES THE REDUCTION OF GROSS PAY BY THE AMOUNT OF DEDUCTIONS INDICATED
ABOVE. THIS DOCUMENT AUTHORIZES THE CONTIUATION OF DEDUCTIONS UNTIL WRITTEN CANCELLATION IS RECEIVED BY THE
PAYROLL DEPARTMENT.
EMPLOYEE SIGNATURE
DATE
OFFICE USE ONLY
PAYROLL
REPRESENTATIVE
DATE
DATE OF INITIAL
PAYROLL DEDUCATION
VOL
DED #
1608
EMPLOYEE NAME
DATE of FORM
Payroll Ref #
A#
DATE EFFECTIVE
POSITION TITLE
DEPARTMENT
click to sign
signature
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