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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