Learfield IMG College Family Fund Payroll Deduction

Employee Name*

First Name

Initial

Last Name

Home Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Employee Email Address*

Date*

Effective date for deduction

Choose ONE only*

NEW Deduction ADDITIONAL Deduction REPLACEMENT for Existing Deduction Deduction CANCELLATION

I wish to support Learfield IMG College employees and family members through Family Fund for Learfield IMG College Employees (the "Fund"). I understand that this authorization for Payroll Deduction will remain in effect until employment separation, or the pledge is paid off or cancelled by me in writing.

I Authorize The Following Payroll Deduction:*

Monthly Deduction until Total Pledge is fulfilled Ongoing Payroll Deduction One Time Deduction

Monthly Deduction of* $

Until my Total Pledge is fulfilled* $

Per Month Payroll Deduction of* $

One Time Deduction of* $

NOTE: Deduction forms will be processed immediately upon receipt by Learfield IMG College Payroll Group. Deductions will be effective the following scheduled payroll.

I also authorize Learfield IMG College to remit, or otherwise transfer the above-listed amount(s) to Family Fund for Learfield IMG College Employees. I understand that I may cancel this deduction at any time.

I understand that this authorization shall remain in effect until revoked by me, allowing up to 3 days time to change the payroll records in order to make effective any changes in the deduction. This authorization does not cover deductions for any time prior to the payroll period in which the initial deduction is made.

I understand and further agree that neither Learfield IMG College nor any officer or employee thereof shall be held responsible or liable for any inadvertence or error in withholding or transmitting payroll deductions to the Fund or for any change in the rules and regulations of the Fund, except for monies actually withheld and not transmitted.

In the event there are insufficient earnings to cover all required and authorized deductions, including those required by law, I understand that deductions will be taken in the order of priority assigned by Learfield IMG College.

Family Fund for Learfield IMG College Employees Payroll Deduction Form