2444  Dole  Street,  Bachman  Hall  105,  Honolulu,  Hawai‘i  96822-‐2388  Telephone  808.956.8849        Toll  Free  Telephone  1.866.UH.OHANA  (846.4262)          Fax  808.956.5115  

www.uhfoundation.org  

 University  of  Hawai‘i  Foundation  Salary  Assignment  form  D-‐60  

 Please  fill  in  the  following  information,  some  of  which  is  already  prefilled  for  you.  Please  note  this  is  a  tri-‐section  form  for  the  purpose  of  distribution  to  the  appropriate  areas:      

1. Department:         University  of  Hawai‘i  2. Sub-‐Division  or  School:    UHM  Library  (example)  3. Social  Security  Number   xxx-‐xx-‐xxxx  4. Name:         Last  name,  First  name,  Middle  Initial  5. Type:                   UH    6. Agent:               795    7. Plan:                 leave  blank  8. I.D.  No.:               leave  blank  9. Department:               F    10. ASSIGNS  or  CANCEL  box:     Click  on  the  appropriate  box    11. Enter  the  amount  you  plan  to  give  the  “first  month.”      

Please  do  not  fill  in  the  “each  month  thereafter”  line  unless  the  amount  differs  from  the  “first  month.”    12. Effective  payroll  dates:  

a. Enter  the  date  you  would  like  your  deductions  to  begin,  AND    b. Enter  the  ending  date  only  if  you  want  the  deductions  to  stop  at  that  date,  OR  c. Enter  a  commitment  amount  only  if  you  want  the  deductions  to  stop  at  the  amount.    d. DAGS  prefers  either  just  an  end  date  or  a  commitment  amount  –  not  both.  

 Note:  If  there  is  no  end  date  or  commitment  amount,  the  deductions  will  continue  until  you  send  us  a  cancellation  form.      

 13. Select  the  “Print  Form”  then  Sign  and  Date  the  “I  certify”  box  in  the  lower  left-‐hand  corner  in  each  of  all  3  

sections.  (Signatures  must  be  in  DARK BLUE INK).  14. In  Upper  Right  Corner  please  write  in  the  name  and  account    you  wish  to  support,    

(EXAMPLE:  Library  Enrichment  Fund  120-‐3101-‐4)  15. On  a  separate  page  please  include  a  home  and  business  address  for  our  records,  and  a  business  phone  should  

we  have  any  questions  regarding  this  form.    16. Send  all  three  copies  to:  UH  Foundation,  Bachman  Hall  105  for  processing  (allow  a  minimum  of  10  business  

days).  UHF  will  forward  to  the  DAGS  Payroll  office  by  the  first  work  day  of  each  month  to  be  included  as  a  deduction  for  that  month.  

17. Sign  and  Date  the  “I  CERTIFY”  box  on  the  bottom  left  hand  corner  on  all  3  sections.    

 To  make  changes  or  additions  to  an  already  existing  payroll  deduction,  please  call  Lynnette  Lum  at  956-‐5110  or  e-‐mail  her  at  lynnette.lum@uhfoundation.org    to  process  updates.    

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UCERA University Clinical, Education and Research Associates

677 Ala Moana Blvd., Suite 1025, Honolulu, HI 96813

Phone: (808) 585-2881/ Fax: (808) 535-5976 P:\Forms\Parking Salary Reduction Agreement Revised 11/27/06

Miscellaneous Voluntary Payroll Deduction Agreement

This form should be filled out in its entirety and be submitted to Human Resources at least 30 days prior

to the effective date. (Please type or print clearly)

Employee's Name (Last, First, Middle Initial) Social Security Number

XXX-XX-

Work Phone Department

PPaayyrroollll DDeedduuccttiioonn

I, _____________________________________________________________________ hereby authorize

UCERA (Employer) to deduct from my wages the sum of $_________________, per ________________

beginning _____________ and ending ________________ until the total amount of $________________

has been deducted. In payment for: _______________________________________________________.

Agreement

I agree to have UCERA reduce my net pay by the amount I have elected above. I understand that in

the event my employment ends for any reason before the final deduction is made, the entire balance will

be deducted from my final wages.

Employee Signature: Date:

Authorized by: Date:

Dean/Chair/Supervisor

Warrant&Disb: Code:

AssignORCancel: OffCutLine1: Reset Form: Print Form: Department: University of HawaiiSchool: SSN: Name: ID Number: Dept: FAssignFirstMonthAmount: AssignAfterMonthAmount: EffectivePayrollDate: EndingDeductionsDate: CommitmentAmmount: Copy: STATE COMPTROLLER (CENTRAL PAYROLL)Copy2: AGENT COPYCopy3: EMPLOYING AGENCY (PERSONNEL JACKET FILE COPY)Cut Line 2: AssignsOptions: Off