PAYROLL DEDUCTION
Contact vruh@wustl.edu for questions.


INDIVIDUAL INFORMATION

Semester*
Semester Year*
Student Name*
Employee Name (If different from student)
Employee Address
Hire Date*

COURSE INFORMATION

$
Payroll Type*

NOTE: Balances less than $200 will be deducted in one installment. Balances of more than $200 can be deducted in multiple paychecks.

Fall / Spring: The account balance will be deducted in either 4 monthly or 8 biweekly installments and will begin on the next available paycheck. 

Summer: The account balance will be deducted in either 3 monthly or 6 biweekly installments and will begin on the next available paycheck.

I hereby authorize the Washington University Payroll Department to immediately begin deducting the amount below per paycheck for the number of paychecks below from my salary to pay the balance owed to University College. If I should terminate my employment at Washington University before the balance is paid in full, I authorize Washington University to deduct the balance from my final paycheck. If this deduction does not occur, I realize that I am responsible for any outstanding balance and collection charges that may result.

$
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Date*

APPROVAL SECTION

Approved Date*
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Progress