Pa
y
roll Deduction
Date
Employee or Student’s Name (Please print) Banner ID
Deduction Codes (DC)
Accounts Receivable (Undergrads & Employees ONLY)
Payroll DC# 506 Summer 507 Fall 505 Spring
Graduate Payroll Deduction (Grads ONLY)
Payroll DC# 521 Summer 522 Fall 520 Spring
Agreement
By signing below, I acknowledge and agree that installments of $
will be deducted each pay period for a grand total of $ and applied towards DC#
designated.
Employee or Student Signature Date
BUSINESS OFFICE USE ONLY
Students Acct’s Signature Date
Payroll Deduction Cancellation Date
(signature or authorization-i.e. phone)
Submit original form to Payroll. Submit a copy to Student Accounts. Submit a copy to Travel. The
student should also retain a copy.
Revised 12/07/09
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