Fillable Printable Payroll Deduction Authorization Form - Indiana

Payroll Deduction Authorization Form - Indiana

IUP FACULTY / STAFF ACTIVITY FEE

PAYROLL DEDUCTION AUTHORIZATION FORM

Student Cooperative Association

Hadley Union Building

319 Pratt Drive

Indiana, PA 15701

IUP Payroll Services

G11 Sutton Hall

1011 South Drive

Indiana, PA 15705

I certify that I am an employee of IUP, and I am applying for participation in the Faculty / Staff Activity Fee Payroll Deduction

Program. My personal information is as follows:

NAME (LAST, FIRST, MI) EMPLOYEE IDENTIFICATION NUMBER

I authorize IUP Faculty and Staff Payroll Services to begin payroll deductions as payment to the Student Cooperative Association

for my activity fee.

will be deducted in equal payments for the following

I understand that the total activity fee amount of

number of pays: (choose an option)

5 pays

10 pays

I understand that if for any reason payroll deductions cannot be continued through IUP, that I am responsible to pay any

outstanding activity fee balance directly to the Student Cooperative Association.

I authorize IUP and the Student Cooperative Association to share all information necessary to complete those tasks necessary

to collect this debt, including employment, address, and outstanding balance information.

Note:

Payroll deduction option preference may change pending verification of employee pay status.

Faculty / Staff Payroll Services will contact you if a change is required.

SIGNATURE DATE

Student Cooperative Association Use Only

IUP Faculty / Staff Payroll Services Use Only

Please Return this completed form to: The Student Cooperative Association

Hadley Union Building

319 Pratt Drive

Indiana, PA 15701