SOUTHEASTERN LOUISIANA UNIVERSITY
PAYROLL DEDUCTION AUTHORIZATION

            I hereby authorize Southeastern Louisiana University to deduct from my salary until further notice the amount of ___________________ per pay period for deposit in the 

SOUTHEASTERN DEVELOPMENT FOUNDATION

Phi Kappa Phi Lou Ballard Endowed Scholarship
Restrictions (if any) 
________________________________________
Employee’s Dept./Phone No.

I further, hereby waive on behalf of myself, my heirs, successors, and assign any and all rights of action against Southeastern Louisiana University and/or the State of Louisiana (and any officer, employee or agency thereof) arising out of the deduction, nondeduction, processing, or any other handling of the named voluntary deduction.
 
Employee Signature  ______________________________________________________
Address  ______________________________________________________
 City, State, Zip  ______________________________________________________


EMPLOYEE NAME ___________________________________________________________
PEOPLESOFT EMP. ID ___________________________________________________________
SOCIAL SECURITY # ___________________________________ EFFECTIVE DATE _________
VENDOR NAME SOUTHEASTERN DEVELOPMENT FOUNDATION
BENEFIT PLAN DEVELOPMENT FOUNDATION


FOR OFFICE USE ONLY:
CAFETERIA PLAN ITEM:     YES _________  NO _________  N/A ____X____
 
ANNUAL AMOUNT _____________________ MONTHLY AMOUNT _____________________
GOAL AMOUNT _____________________ BIWEEKLY AMOUNT _____________________
BEGINNING DATE: _____________________ 1st PAYDAY IN: _____________________
2nd PAYDAY IN: _____________________

VENDOR
SIGNATURE _____________________________________________   DATE ________________

THIS FORM SUPERSEDES AND REPLACES ALL PRIOR AUTHORITY FOR THIS DEDUCTION



PAYROLL ___________________  POSTED BY: _______________  DATE ________________