Voluntary Payroll Deduction Authorization/Cancellation Form

I hereby authorize the Controller of the City and County of San Francisco to deduct from my salary each pay period the amount stated above and to transmit the deducted amount to the organization named above.

I consent to the City adjusting the deduction amount if necessary to conform to any pay period changes. This authorization shall be in full force and effect until (1) I cancel it using this form and submit the form to the Office of the Controller, Payroll Division, 1 Dr. Carlton B. Goodlett Pl., Rm. 488, San Francisco, CA 94102, or (2) the organization receiving deductions cancels it.

I acknowledge that I must report any discrepancies in the deductions as reflected on my pay statement to the Payroll Division in writing and within not more than 30 days after the deduction.

DISCLAIMER: By signing this form, the City Employee requesting the Controller’s Office Payroll Division to process a deduction acknowledges that the Controller’s Office Payroll Division does not review or monitor the charitable status of any recipient organizations and makes no representation regarding whether any deduction may be claimed as a tax deduction, credit, or exemption for personal income tax purposes.

I hereby request the Controller of the City and County of San Francisco to cancel the salary deduction named above. I understand that the ability to cancel the deduction may be subject to certain restrictions or requirements and that it is my responsibility to meet all necessary requirements before submitting this request.