Relay for Life Payroll Deduction Modification

Relay for Life Payroll Deduction Modification

Complete the form below to modify or cancel any current Relay for life Payroll Deductions that are being deducted from your paycheck. Please allow 1-2 weeks for changes to take effect.

Employee Name:*
First Middle Last
Employee ID*
Home Address:*
Street Address Address Line 2 City State ZIP Code
Home Phone / Cell*
Email Address
Current Amount Being Deducted Per Pay Period (Week)*
- $1.00
- $2.00
- $5.00
- $10.00
- $20.00
Requested Amount To Be Deducted Per Pay Period (Week)*
- CANCEL Weekly Deduction
- $1.00
- $2.00
- $5.00
- $10.00
- $20.00
Employee Initials:*
Date
MM slash DD slash YYYY

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