CITY OF LITTLE ROCK
VOLUNTARY DEDUCTION AGREEMENT
Dailey Fitness Center
Employee Name_______________________________Social Security Number___________________
Department___________________________________Employee number_______________________
This authorization will be effective the first day of the following month with the payroll deduction
coming out once a month from the last pay period in the month. If you would like to use the center in
the current month, please take a copy of this authorization to the center and you can pay a prorated fee
for the remainder of this month.
$
10.00
Employee Only
Employee + Family
$
15.00
Authorization
I hereby authorize the City of Little Rock to withhold from my payroll check the voluntary deduction
indicated above.
This authorization is to remain in force until the City of Little Rock receives notice of cancellation
from me. This notice of cancellation must be received by the benefits office no later than Friday
before payday to be effective the following payday Friday.
Signed____________________________________________Date_______________________________
Cancellation
I hereby cancel the authorization for the City of Little Rock to withhold from my payroll check the voluntary
deduction indicated above. Effective Date ____________ Signed ________________________
Fax back to Benefits 371-4496
For Departme
nt Use Only
Information verified as to accuracy
and entered into payroll system? Yes No
____
___________________________________ _____________________________
(
Signature)
(
Date)
click to sign
signature
click to edit
![]()
