Donating by deduction at source

Deduction at source form

"*" indicates required fields

Name*

First name Last name

Employee number*

Direction*

Personal address*

Street Address Address Line 2 City Postal code

Phone*

Personal e-mail*

Salary deduction

I authorize the CIUSSS du Centre-Sud-de-l' Île-de-Montréal Payroll Department to deduct from each of my paychecks the amount of:*

Signature

Signature*

Enter your name

Today's date*

Acceptance*

By checking this box, I agree that the CIUSSS du Centre-Sud-de-l’Ïle-de-Montréal’s payroll department may deduct the amount indicated in the “salary deduction” section from each pay.

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To stop or change a payroll deduction, contact your payroll department.

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Donating by deduction at source

Deduction at source form

Salary deduction

Signature

Sending your form by internal mail

Modifying your deduction at source

Partners