If you placed a deduction on your paycheck, you may request to cancel that deduction by submitting this form to our office.  This request must be received by our office at 9:00 am on the 10th and 25th in order to be effective the following pay period.

Note that deductions initiated by other agencies (such as taxes, loans, levies or garnishments) may not be stopped by you.  In these instances, you may wish to contact the agencies responsible.

Form Instructions

Complete the following:
- Your Name
- Name of the company with the deduction
- Effective date to stop deduction
- Social Security Number

Sign and Date the Form

Bring this form to the Payroll Department in CSB 244