Staff Voluntary Payroll Deduction

Staff Voluntary Payroll Deduction - Meal Accounts
Use this form to request voluntary payroll deductions for staff meal accounts and/or the meal accounts of the children of staff.

The deduction will begin with the next payroll if processing time allows but will start no later than the second payroll period after your submission is received.
EMPLOYEE INFORMATION
Employee Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Building Employed*
Email Address*
example@scsd2.k12.in.us

For your reference, below is a chart detailing student meal prices for 2024-25 (per student)

Adult prices:

Breakfast, $2.70

Lunch, $4.80

MEAL ACCOUNTS*

	Meal Account (Student or Staff) First and Last Name	School	Apply how much $ per pay for this individual?
1.
2.
3.
4.

Total Deduction Per Pay for Meal Account(s)
AUTO-CALCULATED. IF this total isn't accurate, be sure the amounts you've input above per individual are dollar amounts (0.00) and not words.

AUTHORIZATION SIGNATURE
I hereby authorize Scott County School District 2 (SCSD2) to have the amounts indicated above deducted semi-monthly (twice per month) from my paycheck for each future payroll until I request in writing (email) a change or to discontinue. The requested deduction will begin with the next payroll following submission if processing time allows but will start no later than the second payroll period after your submission is received. I understand that payroll deductions will continue until I contact the SCSD2 Business Office to cancel or change deductions.*

Clear
SIGNATURE
Today's Date*

MonthDayYear
Date
Email notifications are ENABLED and you will receive an emailed copy of your submission.
Should be Empty:

Staff Voluntary Payroll Deduction - Meal Accounts