Central Payroll Bureau

Payroll Deduction Authorization

Please print or type all information in BLACK INK for electronic imaging

Payroll Type - Check One

Regular

Contact

University of Maryland

Personnel / Payroll Agency Code

(See your pay stub for information)

Agency Name (Place of Employment)

Maryland State Police

Social Security Number

Employee Name

Deduction Action Requested

Name of Deduction

Payroll Cycle

55-FOP 76

Deduction will begin on the next available pay period upon receipt of this form at the State Central Payroll Bureau.

Initiate

Employee Total Biweekly Deduction Amount

Change

Current Amount $

Cancel

New Amount $ 11.00

I authorize the State of Maryland to deduct from my salary the above amount and forward it

to_________________________________________. This deduction will continue until I

submit written notice to change or cancel it on a new authorization form.

_________________________________

_____________________________

Employee Signature

Date

_________________________________

Daytime Telephone Number

I:PUBLIC / FORMS / Payroll Deduction Authorization - final.doc

PN:10383 Revised CPB (07-06)