Office of Human Resources

Rendleman Hall, Room 3210

Edwardsville, IL 62026

618-650-2190

Salary Deferral Revocation Form

I,	(print name)	, request to stop salary
deferral beginning with my next academic year contract. I understand that the current defer pay schedule will continue until my new academic year contract begins. Once salary deferral is revoked, my compensation will be paid as earned over my contract dates beginning with the next year. My salary will be paid over the 9 (10, or 11) month academic contract and will not be paid over 12 month. This request is in effect until changed. To request salary deferral for a future year, I must submit a new Salary Deferral Authorization Form.

There is no penalty or fee to opt-out of salary deferral. However, per the IRS, the revocation can only begin with a new academic year. I am aware that if I have payroll deductions for health, life and dental insurance, I will be billed those amounts directly from Central Management Services during the summer months when I have no pay. This Salary Deferral Revocation Form is only effective if submitted to Payroll prior to the first day of my contract for the year it is to become effective.

All information below must be completed. Payroll will send a confirmation e-mail to verify the request has been received.

Signature
Date
Banner ID No.
E-mail
If you have questions please refer to Salary Deferral Guideline, the FAQ’s or contact Payroll at 650-2190.

DO NOT WRITE BELOW THIS LINE

Date Received by Payroll: _______________________________________________________

Confirmed by E-mail on: ____________________________________________________

Payroll Entered on: _______________________ Initials: __________________________

3/2012

Offices of Human Resources

rajohns

2012-04-19

Joyree Chura

SIUE