COP-9 Form: WAGE AND DEDUCTION ADJUSTMENT FORM



WAGE AND DEDUCTION ADJUSTMENT FORM STATE OF CONNECTICUT

COP-9 REV. 12/15 OFFICE OF THE STATE COMPTROLLER

AGENCY Attach Check/Direct Deposit Advice to be cancelled and three copies of this form and return to

OFFICE OF THE STATE COMPTROLLER, PAYROLL SERVICES DIVISION Keep copy for your records.

|DEPARTMENT |DEPARTMENT ID. |PAY GROUP |CHECK # |

| | | | |

|EMPLOYEE NAME |SOCIAL SECURITY NUMBER |EMPLOYEE NO. |

| |xxx-xx- | |

|PLUS |PAY PERIOD |PAY PERIOD |DATE OF |EARN CODE |EARN CODE |

|MAINT |BEGIN |END |CHECK |& AMT |& AMT |

| | | | | | |

| | | | | | |

|DEDUCTIONS |RETIREMENT |DUES/FEES |OTHER | HEALTH//DENTAL INSURANCE (Pre-Tax) |SUBTOTAL LINE 2 |

| | | | | | |

| CODES | | | | | | | |

| | | | | | | | |

|DOLLAR AMOUNT | | | | | | | |

|DEDUCTIONS |DEF COMP/TSA |CREDIT UNION |AUTO INS. |LIFE INS. |MISCELLANEOUS (Pre-Tax) |SUBTOTAL LINE 3 |

| | | | |(Pre-Tax) | | |

| CODES | | | | | OPE2 | OPEB | |

| | | | |

|DOLLAR AMOUNT | | | |

| | | | |

| | | | |

|Deposit ID # |AUTHORIZED SIGNATURE |DATE SIGNED |

| | | |

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