Fillable Form SI 9058 CSU Payroll Deduction Authorization

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Form SI 9058 CSU Payroll Deduction Authorization

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SI 9058-101770 (2/11)
The California State University
Payroll Deduction Authorization
Ded/Org Code Last Name First Name M.I. Social Security No.
Organization Name
I hereby authorize the State Controller to deduct from my salaries and wages the amount specified now or
in the future for membership dues and any benefit program for which I have applied, which is sponsored by
the above named organization.
This authorization will remain in effect until cancelled by me or by the above named organization.
I certify I am a member of the above named organization and understand that termination of membership
will cancel all deductions made under this authorization.
Signed Date
Return this form with your application to Standard Insurance Company in the envelope provided.
Standard Insurance Company
075-130: Vol AD&D
075-131: Vol LTD
075-117: Vol Life
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Form SI 9058 CSU Payroll Deduction Authorization

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Completed 23 February 2020

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