Payroll Deduction Form for Senate Scholarships

Laney College Faculty Senate

Scholarship Fund

Authorization of Payroll Deduction Contribution

Employee ID Number      __________________

Last Name                                                 First Name                                                Middle Initial

Amount $______________

I hereby authorize the Peralta Community College District to deduct the above amount in monthly installments from my regular salary warrants commencing with the payroll period following receipt by the District of the authorization, subject of its regular business procedures.  I further authorize the District to remit the amounts to the Laney Faculty Senate Scholarship Fund.

This authorization will remain in effect until I terminate or revoke it in writing.

Signed _______________________________  Date _______________

If you wish to make your payroll deduction retroactive to a prior month, complete the following.

I hereby authorize retroactive payroll deduction to begin ____________ and to continue at $___________per month on current payroll schedules.

Note:  All contributions to the Laney College Faculty Senate Scholarship Fund are tax deductible as charitable contributions to the Peralta Foundation.

This payroll form may be returned to:

Louis Quindlen, Laney Faculty Senate Treasurer