Account Owner’s (Employee’s) Name (Print) Account Owner’s Social Security Number
Last First MI
Employer’s Name and Mailing Address (Print) Address City State Zip
Employer’s Telephone Employer’s Federal Tax ID Number
PAYROLL DEDUCTION (Check One)
New Deduction Change in the Present Deduction Terminate Deduction
Amount to deduct from salary each pay period: $
Pay Period or Date the payroll deduction is to begin:
ACCOUNT(S) IN WHICH THE PAYROLL DEDUCTION WILL BE DEPOSITED
Enter the account(s) that are to receive the deposits. If you have more than one account, you must enter the percentage of the
total amount deducted from your pay that is to be credited to each account. The sum of the percentages entered must equal 100%
Percentage of Total Deduction
%
%
%
%
%
Total 100%
EMPLOYEE’S (ACCOUNT OWNER’S) AUTHORIZATION
I understand that these instructions will remain in effect until changed or cancelled by me. The START Saving Program is a
voluntary program, and I understand that I am under no contractual obligation and, therefore, may cancel this authorization or
changethedeductionamountatanytimeuponnoticationtoSTARTSavingProgramandmyemployer.Iherebyauthorize
myemployertocancelanypriorSTARTSavingProgramdeductionformsonle.Iherebywaive,onbehalfofmyself,
my heirs, successors, agents and assigns, any and all rights of action against the State of Louisiana, its agents, and assigns,
arising out of the deduction, failure to deduct or any other handling of this request for payroll withholding.
Account Owner’s Signature:
Date:
Approved date: Initials:
LOUISIANA’S START SAVING PROGRAM
PAYROLL DEDUCTION AUTHORIZATION FORM
START Saving Program
PO Box 91271
Baton Rouge, LA 70821-9271
Telephone: 1-800-259-5626
Internet: www.startsaving.la.gov
Fax: (225) 612-6497
Revised 08/07/2012
INSTRUCTIONS: To initiate deposits to your account or that owned by your spouse through payroll deduction, you must complete
this form. Follow these
instructions to complete this form. Type or print in ink. Enter your employer’s complete company name, address,telephone number
andFederalTaxIdentication(ID)Number.Ifnecessary,contactyourpayrolldepartmenttoobtainyouremployer’sInternalRevenue
Service Federal Tax ID Number. If you have more than one account, enter the percentage of the total payroll deduction you wish to be
deposited to each account. The percentages allocated to all accounts must equal 100%. Mail the completed form to the “START Saving
Program,” at the address shown above. If you need assistance in completing this form, call a Public Information and Communications
Ofceratthenumbershownabove.
