AUTHORIZATION TO WITHHOLD CAMPUS CARD DECLINING
BALANCE DEPOSIT AMOUNTS FROM PAYROLL

NAME: ________________________________

SOCIAL SECURITY #: ____________________

DEPARTMENT: _________________________

BI-WEEKLY PAYROLL
DEDUCTION AMOUNT: $__________________**

EFFECTIVE DATE: ______________________

This is a first time payroll deduction request

This is a change to my current deduction amount

Please end my deduction as of the effective date
listed above.

SIGNATURE: ____________________________

**A mimimum $5 bi-weekly payroll deduction amount must be requested to be eligible.

AMOUNTS WITHHELD FROM PAYROLL TO BE DEPOSITED TO YOUR CAMPUS CARD DECLINING BALANCE ACCOUNT WILL BE AVAILABLE FOR USE EFFECTIVE EACH PAY DATE.