SALARY DEDUCTION FORM

GREEN FUN RACERS 3.0

Important:

Ø For regular non-teaching associates (AS, ASP, ASF, FTF) and full-time faculty (ASF, FTF) only.
Ø Please accomplish this form in two (2) copies and submit to the Office of the Vice President for Advancement.
Ø The registration fee will be charged in two equal deductions in two pay days:
o AS, ASP, ASF & FTF – January 10 & 25
o SS – January 15 and 30

To: Finance Department c/o Office of the Vice President for Advancement

Please deduct the following amount from my salary for the period January 1 - 15, 2019, and January 16 - 30, 2019 representing the registration fee for
the DLSP’s TakBro 2019 activity to be held at the Vermosa Estate, Imus, Cavite on January 27, 2019, for the benefit of the professional development of
the faculty of St. Joseph School-La Salle, De La Salle Andres Soriano Memorial College and De La Salle John Bosco College: (Please check appropriate
box)

For Runners:

o P 700 - 3 KM
o P 750 – 5 KM
o P 850 – 10 KM

For associates who will subsidize the registration fee of student athlete:

o P 700 - 3 KM Number of student: _______

o P 750 – 5 KM Total amount: _______
o P 850 – 10 KM

Total amount subject for Salary Deduction (in words): _____________________________________________

I understand and acknowledge the deduction may not be made in full if I have insufficient income to maintain a 25% net take home pay during a pay
period.

I understand deductions may not take full effect during the current payroll cycle.

I will not hold DLS-CSB liable for any deductions that are not made.

In the event my employment ends for any reason before the final deduction is made, the entire balance may be deducted from my final
pay/retirement pay/separation pay/CEAP or RCBC proceeds.

_________________________________ __________________ _______________ ________________

Associate’s Printed Name and Signature Classification ID Number Department

Thank you.

ACKNOWLEDGEMENT: Office of the Vice President for Advancement

__________________________________ __________________ ______________

OVP-ADV Representative’s Name in Print Signature Date Signed