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Deduction at source form

"*" indicates required fields

Name*
Personal address*

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

Enter your name
MM slash DD slash YYYY
Acceptance*

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