PAYROLL DEDUCTION AUTHORIZATION
UNION DUES

I hereby authorize Southern Illinois University Edwardsville to deduct the amount indicated on this card from

my pay each month. This deduction is to be made in accordance with the State Salary and Annuity Withholding Act.

Deduction for:	Per Pay Amt	$
Organization
Name:	Banner ID Number:
Street:
City:	State:	Zip:
Effective Pay Period:	Payroll ID:

SIGNATURE:
DATE:
5/7/12 – previous versions obsolete

PAYROLL DEDUCTION AUTHORIZATION
UNION DUES

I hereby authorize Southern Illinois University Edwardsville to deduct the amount indicated on this card from

my pay each month. This deduction is to be made in accordance with the State Salary and Annuity Withholding Act.

Deduction for:	Per Pay Amt	$
Organization
Name:	Banner ID Number:
Street:
City:	State:	Zip:
Effective Pay Period:	Payroll ID:

SIGNATURE:
DATE:
5/7/12 – previous versions obsolete

REVOCATION OF PAYROLL DEDUCTION

OIT

2012-05-14

Joyree Chura

SIUE