For Parking Office use only
Permit Number Vehicle registration fee Deduction(s) Date Issued Initials
MSU Billings Parking
657-1704
Montana State University Billings
Payroll Deduction Authorization Form
2011-2012
I am a faculty/staff person who receives employee benefits and I wish to participate
in the Pretax Parking Program. (Student workers are not eligible.) I authorize the MSU
Billings Payroll Office to make deduction/s from my payroll check/s until such time as the fee
amount has been fulfilled. Deductions are limited to payroll disbursements 9/23/11 through
5
/4/2
012. I understand that, should I leave university employment during its term, the permit
must be returned or I may be billed for any unpaid balance.
Please return this form and your completed vehicle registration slip to the University Police &
Parking office no later than September 7
th
, 2011. DO NOT return forms to the Human
Resources office.
Personal Information (Must be filled out completely.)
_________________________________________ _______________
Name (Last, First, MI)
ID Number
______________________________________________________________ ______________________
Department
Dept. phone
__________________________________________________ __________________
Employee Signature
Date
Please check appropriate box for deduction preference:
(If you don’t select 1 or 17, we’ll select 1 for you.)
Annual parking permit ($75.00, 1 time deduction)
Annual parking permit ($75.00, $4.41 for 17 deductions)
Reserved parking permit ($150.00, 1 time deduction)
Reserved parking permit ($150.00, $8.82 for 17 deductions)
