2. Payroll Deduction
   Please complete form, print, sign, and return to Susan in Payroll.
4. Employee Name
5. Department
6. Effective Date
   Effective Date
8. Deduction

   1. RSA-1
9. Change my deduction from
10. Change my deduction to
12. Deduction

    1. Valic
13. Change my deduction from
14. Change my deduction to
16. Deduction

    1. Do
    2. Do Not

    Union Dues
17. Union Dues
18. Union Group
20. Deduction

    1. United Way
21. Change my deduction from
22. Change my deduction to
24. Deduction

    1. FOP Dues
25. Change my deduction from
26. Change my deduction to
28. Deduction

    1. Police Benevolent Fund
29. Change my deduction from
30. Change my deduction to
32. Deduction

    1. Law Enforcement Memorial Fund
33. Change my deduction from
34. Change my deduction to
36. Deduction

    1. AFLAC
37. Change my deduction from
38. Change my deduction to
40. Deduction

    1. Sun Life Insurance
41. Change my deduction from
42. Change my deduction to
44. Deduction

    1. Monumental Life Insurance (Long Term Care)
45. Change my deduction from
46. Change my deduction to
48. Deduction

    1. Standard Insurance
49. Change my deduction from
50. Change my deduction to
52. LABEL

    1. LABEL @
53. Change my deduction from
54. Change my deduction to
56. Deduction

    1. OTHER
57. Change my deduction from
58. Change my deduction to
60. Please stop my direct deposit effective
62. Employee Signature
    After printing, please sign here.
Leave This Blank:


63. Print Only

* indicates a required field