STATE OF ARIZONA VOLUNTARY DEDUCTION

STATE OF ARIZONA AUTHORIZATION TO START, CHANGE, OR STOP A VOLUNTARY DEDUCTION
FULL NAME
LAST, FIRST
EIN NUMBER
EMPLOYEE IDENTIFICATION NUMBER
WHAT ORGANIZATION DO YOU WISH TO DROP
FOP RATE
ACA RATE
AZCPOA RATE
CODE FOP
CODE ACA
CODE AZCPOA
FOP DROP DATE

MonthDayYear
Date
ACA DROP DATE

MonthDayYear
Date
AZCPOA DROP DATE

MonthDayYear
Date
I hereby request and authorize the State of Arizona to deduct from my pay any deductions I have indicated above as a start or change. I hereby request and authorize the State of Arizona to stop deducting from my pay any deductions I have indicated above as a stop. This authorization will remain in effect until a new authorization is received. I understand that deductions occur on the first and second paydays of the month (24 times per year) unless indicated with a star (*) which occur every payday (26 times per year).
EMPLOYEE'S SIGNATURE:
TODAYS DATE:

MonthDayYear
Date
Should be Empty:

STATE OF ARIZONA AUTHORIZATION TO START, CHANGE, OR STOP A VOLUNTARY DEDUCTION