VOLUNTARY PAYROLL DEDUCTION TO A STATE AGENCY

Agency Name:
Banner ID Number:
Name:

Street:

City:	State:	Zip:
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

SIGNATURE:
DATE:

5/7/12 – previous versions obsolete

REVOCATION OF PAYROLL DEDUCTION

OIT

2012-05-14

Joyree Chura

SIUE