REVOCATION OF PAYROLL DEDUCTION
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|VOLUNTARY PAYROLL DEDUCTION TO A STATE AGENCY |
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|Agency Name: | |
| | |
|Banner ID Number: | | |
| Name: | |
| | |
| | |
|Street: | |
| | |State: | |Zip: | |
|City: | | | | | |
|Department: | |
| | |
|I hereby authorize the State of Illinois or SIUE to deduct from my earnings $ | |each pay |
|period and continuous until revoked. I reserve the right to revoke this authorization at any time by submitting a written Revocation form. This deduction is to |
|be in accordance with the established rules of the State Salary and Annuity Withholding Act. |
| |
|Faculty Staff (paid Semi-monthly) Staff (paid Bi-weekly) |
| | | | |
|Effective Pay Period | | | |
| | |DATE: | |
|SIGNATURE: | | | |
5/7/12 – previous versions obsolete
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