Staff Voluntary Payroll Deduction

Staff Voluntary Payroll Deduction
Employee Name

First NameLast Name
Building Employed
Email
example@example.com

Funds To Be Deducted

Rows	Student (or Staff)Name	School	How much per pay?	Funds Used For?(lunch, preschool, repairs, etc.)
1.
2.
3.
4.

Total Deduction Per Pay
Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: