MMC-TC Payroll Deduction Authorization Agreement for Providence Farm
Please complete by May 31, 2019
I authorize deduction from my net pay for Providence Farm CSA Share
Check which share type you are choosing:
22 Week Small Family Share (feeds 2-4 people) - $748 (June 20 - Nov 14, 2019)
22 Week Large Family Share (feeds 5-8 people) - $968 (June 20 - Nov 14, 2019)
Half Share of 22 week Small Family Share (feeds 1-2 people ) $374. Pair up with co-worker on your own. (June 20 -Nov 14, 2019)
Biweekly (11 weeks) Small Family Share (feeds 1-2 people) - $418 (A week: June 20 - Nov 7 every other week)
Biweekly (11 weeks) Small Family Share (feeds 1-2 people - $418 (B week: June 27- Nov 14 every other week)
Deductions begin with pay date: June 21, 2019
Amount to be deducted per pay period
$68 per pay period (small) 22 weeks
$88 per pay period (Large) 22 weeks
$34 per pay period (1/2 share) 11 weeks: Please answer the next question
$38 per pay period (biweekly) 11 weeks: A Week or B week
For the $34/pay period option only: Name of the person you are sharing with?
I authorize the above deduction per check until the total loan amount is paid. If my employment is terminated before the total is paid, I understand the balance is due upon termination and will be deducted in total from my final PTO payout. If any balance is due after that deduction, I agree to pay Munson Medical Center within 15 days from the date of my termination.
Send me a copy of my responses.
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