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STOCKBRIDGE-MUNSEE COMMUNITY EMPLOYEE PAYROLL DEDUCTION REQUEST FORM o

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STOCKBRIDGE-MUNSEE COMMUNITY
EMPLOYEE PAYROLL DEDUCTION REQUEST FORM
Date of Request: _________________________
Employee Name _________________________ Employee number________________
TYPE OF REQUEST:
o Initiate new deduction
o Make Change to current deduction
(If changing a current deduction, please enter your new weekly deduction in “amount of
requested weekly deduction”)
o Stop current deduction
TYPE OF DEDUCTION:
o Stockbridge-Munsee Health and Wellness Center
o Stockbridge-Munsee Community Education Department
o Pow Wow T-Shirts
o Mohican Family Center (Merchandise)
o Pine Hills Golf Course(Membership/Merchandise)
o Arvid E. Miller Library Museum (Merchandise)
o Little Star Convenience Store (Merchandise)
o Mohican LP Gas Account Number: ______________
o Elderly Snow Removal (Minimum $20.00 per week)
o Mohican Loan Department
o Home Loan Account Number: ______________
o Student Loan Account Number: ______________
o Personal Loan Account Number: ______________
o Stockbridge-Munsee Utilities Account Number: ______________
o Mohican Housing Account Number: ______________
AMOUNT OF REQUESTED WEEKLY DEDUCTION: $ _______________
REQUESTED START DATE: ___________________
REQUESTED END DATE: _____________________
TOTAL AMOUNT OWED, IF APPROPRIATE: $___________________
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STOCKBRIDGE-MUNSEE COMMUNITY EMPLOYEE PAYROLL DEDUCTION REQUEST FORM o

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Completed 27 January 2021

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