Fillable Payroll Deduction Authorization (California State University, Los Angeles)

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Payroll Deduction Authorization (California State University, Los Angeles)

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Payroll Deduction Authorization
Name:_______________________________________ SSN:______________________
Home Address: (please print)
______________________________________________ Home Phone:________________________
______________________________________________ Office Ext.:_________________________
______________________________________________ Div/Dept:__________________________
I authorize California State University, Los Angeles to deduct $_______________ each pay period for the
following program: _________________________________________________. I understand that this
deduction will take effect in 4 to 6 weeks from the date received in University Advancement (Adm. 809). I
further understand that this authorization will remain in effect until I notify University Advancement in writing
6 weeks prior to the date I wish the deduction to cease.
_____________________________________________________ _____________________
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Payroll Deduction Authorization (California State University, Los Angeles)

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Completed 18 August 2020

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