Payroll Deduction Authorization and Waiver of Benefits Form
Enrollment form must be submitted to begin deferral. If not enrolling at this time, enter 0. Signature. Date; Print Name. I have submitted enrollment forms for benefits, and I authorize the above listed deductions from each bi-weekly paycheck for this purpose. Deductions will begin the payroll date for the pay period which includes the date benefits are effective. I understand that the amounts ... ................
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