I, _____________________________, request that the SCHOOL ...



I, _____________________________, request that the SCHOOL DISTRICT TAX checked below be deducted from my biweekly salary effective _______________.

* denotes new school districts

_____391664 Adena LSD (Ross) * _____390005 Arcanum Butler LSD (DARKE)

_____391638 Berne Union LSD (Fairfield) _____391618 Bexley CSD (Franklin)

_____390098 Big Walnut LSD _____390109 Bloom-Carrol LSD

_____390007 Bradford EVSD _____390009 Buckeye Valley LSD

_____390011 Canal Winchester LSD _____390119 Carlisle Warren LSD

_____390012 Cedar-Cliff LSD _____391543 Celina LSD

_____390013 Centerburg LSD _____391519 Covington EVSD

_____390091 Eaton City LSD _____390023 Evergreen LSD (Fulton) *

_____390024 Fairbanks LSD _____390025 Fairborn LSD OH

_____390026 Fairfield Union LSD _____390092 Franklin-MO LSD

_____390094 FT. Loramie LSD _____390030 Goshen LSD OH

_____390031 Greenview LSD _____390032 Greenville LSD

_____390033 Hardin-Houston LSD _____390036 Highland LSD OH

_____390037 Hillsboro CSD _____390099 Jefferson LSD

_____391670 Jonathan Alder LSD (Madison) * _____390122 Johnstown – Monroe LSD (Licking)

_____391672 Lancaster CSD (Fairfield) _____390040 Lbrty-Union LSD

_____391521 Licking Vly LSD _____391642 Logan Elm LSD (Pickaway)

_____391643 London CSD _____390042 Madison LSD OH

_____390108 Mechanicsburg EVSD _____390044 Miami East LSD

_____390095 Mt. Gilead EVSD _____390010 National Trail LSD

_____391623 New Bremen LSD (Auglaize) _____390112 New Lebanon LSD (Montgomery)

_____390115 Newark City LSD _____390050 Newton LSD OH

_____390052 Northmor LSD OH _____390113 Northridge LSD

_____390053 Northwestern LSD (Hamilton) * _____390061 Pickerington LSD

_____390062 Piqua LSD _____390064 Preble-Shawn LSD

_____390065 Reynoldsburg SCH _____390097 Riverside LSD (Logan)

_____391644 Ross LSD _____391549 Salem LSD

_____391645 Shelby CSD (Richland) * _____391541 Springfield-Beckley JEDD

_____390069 Southeastern LSD (Clark) _____391567 Southeastern LSD (Ross)

_____391678 Southwest LSD (Hamilton) * _____390070 S/W Licking LSD

_____391630 Talawanda CSD (Butler) _____390073 Teays Vly LSD

_____390074 Tri-Village LSD _____391680 Troy CSD (Miami) *

_____391597 Twin Valley LSD (Preble) _____390079 Valley View LSD

_____391627 Versailles EVSD SD (Darke) _____390126 Walnut Township LSD

_____391599 Wilmington CSD _____390087 Wyoming LSD OH

_____390114 Xenia LSD _____390118 Yellow Springs EVSD

__________________________________ ____________________________

Signature Social Security Number

__________________________________ ____________________________

Work Location Date

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