DEDUCTION AUTHORIZATION FORM
Payroll Office Use Only Received: __________ Entered: __________ Entered by: __________
Complete this form to initiate, terminate, or change a payroll deduction, and submit the completed form to the UVU
Payroll Office (HF 101, MS 109, Fax No. 801-863-7005). A separate form must be completed for each transaction.
To start, change, or terminate an Employee Giving Donation (UVU Fund) payroll deduction, use Development’s electronic form,
https://www.uvu.edu/give/?dids=employee-giving.
Employee Name: _____________________________________________ Employee UV ID No.: _______________
Work E-mail Address: _________________________________________ Work Telephone No.: _______________
I hereby authorize Utah Valley University (UVU) to initiate, terminate, or change the stated payroll deduction, as
indicated on this form.
Deduction Details: Effective Date: _____________
Start a new deduction Terminate a current deduction Change a current deduction
Name of Payroll Deduction/Organization to Receive Deduction: ____________________________________________
Dollar amount or percentage to be deducted each payroll period: $ ________ or % ________
If making a change, CURRENT dollar amount or percentage deducted each payroll period: $ ________ or % ________
This form should not be used to start, change, or terminate an Employee Giving Donation (UVU Fund) payroll deduction. For employee giving
donations, please use Development’s electronic form, https://www.uvu.edu/give/?dids=employee-giving.
1. I understand that if this form is missing any required information or conflicts with previously authorized deductions it may delay the
initiation of the authorized deduction.
2. I understand that if I am initiating a new deduction or changing a deduction the authorized deduction may not take effect on my next
paycheck due to the payroll processing cycle and when my Payroll Deduction Authorization Form is received by the Payroll Office.
3. I understand that if I am terminating a deduction the deduction may still be taken from my next check depending on the payroll
processing cycle and when my Payroll Deduction Authorization Form is received by the Payroll Office.
4. I understand that the deduction may not be taken or a prorated portion of the deduction may be taken if I have insufficient income in
any pay period(s) to cover the deduction and all other required and/or previously authorized deductions. Deduction amounts not
taken may accumulate in arrears with the full arrears amount, or a prorated portion of the arrears amount, to be taken when sufficient
income becomes available.
5. I authorize the Payroll Office to deduct any and all balances I owe the University from pay due to me at termination of employment
with the University.
6. I understand that it is my responsibility to ensure all payroll deductions are taken correctly. UVU is not responsible for the results of
overpayment(s) or missed payments.
7. I understand that this authorized deduction will continue until I terminate employment with UVU or a Payroll Deduction Authorization
Form is received by the Payroll Office to change or terminate this deduction.
Employee Signature: ___________________________________________________ Date: _________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome