APPENDIX E

UNIVERSITY OF NORTHERN IOWA

AUTHORIZATION FOR PAYROLL DEDUCTION

_________________________________________
Last Name, First Name, Middle Name

TO: University of Northern Iowa

I hereby request and authorize you to deduct from my earnings an amount sufficient to provide for the regular payment of the current rate of monthly withholding established by United Faculty. The amount shall be certified by the organization noted and any change in such amount shall be so certified. The amount deducted shall be paid to the organization shown with this form. This authorization shall remain in full force and effect unless terminated by me with written notice to my employer, as provided by law.

_____________________________
Date

_____________________________         _ _______________________________
Employee's Signature                                 Street Address

_____________________________         _______________________________
Social Security Number                             City and State

Cancellation of Authorization to Withhold Wages

Please be advised that I wish to cancel the above authorization to withhold wages

effective with the ____________________________ (month and year) payroll (as provided by law). 

________________________   ______________________________________

Signature of staff member           Date, month and year termination agreement