Kenosha Symphony Orchestra Scheduled Payroll Deduction Form Please print this form, complete, and mail to: Kenosha Symphony Association 6501 Third Avenue Kenosha, Wisconsin 53143

Payroll Deduction Form

Name:___________________________________________________________

Title:____________________________________________________________

Department/Office:_______________________________________________

Company:________________________________________________________

Work Phone:______________________________________________________

Work Email Address:_______________________________________________

SSN:_____________________________________________________________

Home Address:___________________________________________________

City/State/Zip:____________________________________________________

Home Phone:______________________________________________________

Home Email Address:_______________________________________________



Amount of deduction per paycheck: $______________
Starting with first available paycheck.

I hereby authorize the Kenosha Symphony Orchestra to deduct from my paycheck each pay period the amount indicated above.

Signature________________________________________________________

Today's Date:_____________________________________________________

Note: Automatic payroll deduction will remain in effect until revoked in writing to the Kenosha Symphony Orchestra Office.

Your contribution is tax deductible to the extent allowed by law. Please consult with your tax advisor for further infomation.