ALABAMA A&M UNIVERSITY
Payroll Deduction Authorization
(PLEASE PRINT)
Name: __________________________________________SSN:_________ Banner ID:__________________
(Last) (First) (MI) Last 4 Digits
Address: _________________________________________________________________________________
(Street) (City) (State) (Zip)
Daytime Phone Number: (___) _____________________ Email: ____________________________________
Payroll Type: ( ) Monthly ( ) Graduate Assistant ( ) CWSP ( ) Institutional (Bi-Weekly)
Deduction is applicable to other than the employee identified above. Please credit to:
Name: _________________________________________ SSN:_________ Banner ID:__________________
(Last Name) (First Name) (MI) Last 4 Digits
Fall 3; Spring 3; Summer 2
Total Deduction Amount $__________________Amount of Deduction each Pay Period: $____________________.
Deduction Begin Date: _____________________ Number of Deductions ____________
Supervisor’s Name ________________________________ Supervisor’s Office #_______________________
Student Classification: ( ) Graduate ( ) Undergraduate ( ) Special ( ) Other ______________________
Employee Classification: ( ) Staff ( ) Faculty ( ) Administration ( ) Other ______________________
I hereby authorize Alabama A&M. University to deduct the amount (s) from my paycheck as indicated above.
Employee’s Signature: _______________________________________ Date: __________________________
I acknowledge the following:
1. The deduction amount cannot be decreased.
2. The agreement remains in effect until completion, academic year-end, cancellation, or employment separation.
3. Health and Wellness Center deduction
a. Is an advance deduction – applicable to the next month’s membership
b. Cancellation must be made via the Wellness Center by the 10
th
of the month to stop the deduction
4. A new authorization form must be submitted once an agreement has terminated or been cancelled.
5. I am fully responsible for any amounts not payroll deducted.
FOR OFFICE USE ONLY Date Received: _________________________
Requested by: ____________________________________________ Date: _______________________
Department
Comments_____________________________________________________________________________________
_____________________________________________________________________________________________
Alabama A&M University, 4900 Meridian Street, Office of the Comptroller, P. O. Box 1388 Normal, Alabama 35762
