PAYROLL DEDUCT

REGION XIV EDUCATION SERVICE CENTER
PAYROLL DEDUCT
Repayment Option Form - Alternative Certification Program
Date

MonthDayYear
Date
Name
Home Phone
Address
Work Phone
Cell Phone
Mailing Address
City
State
Zip Code
Email Address
example@example.com
*Sample: I, Candice Escobar Social Security# 1234 authorize AnyDistrict ISD to deduct $450.00 for 10 months from my payroll beginning 08/01/2025 - 05/01/2026 for a total of payments equaling $4500.00.
I, Name* Social Security # (last 4 digits), Last 4* authorize Your ISD* ISD to deduct $ Amount ($450.00)* for 10 months from my payroll beginning Date (09-01-2025)* through Date (06-01-2026)* for a total of payments equaling Program Fee Balance (Typically $4500)* .
Student Signature

Clear
Date

MonthDayYear
Date
Alternative Certification Program Facilitator
Date

MonthDayYear
Date
Payroll Manager Signature

Clear
Date

MonthDayYear
Date
If you have questions, or if we can be of service in any way, please call 325-675-8605 or email cescobar@esc14.net .
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