La. Admin. Code tit. 4 § III-139

Current through Register Vol. 50, No. 11, November 20, 2024

Section III-139 - SED-3 (01/06)

DEPARTMENT REQUEST

FOR

PAYROLL DEDUCTION VENDOR

In accordance with the rule governing payroll deductions, Title 4 (Chapter 1, §106. D.2 d),

I,_________________________________________________,________________________________________, on behalf of the

NAME (Print) TITLE

employees of ________________________________________________________________________________, hereby request

DEPARTMENT

favorable consideration of a payroll deduction application submitted by:

A. ____________________________________________________

APPLICANT/VENDOR NAME

____________________________________________________

ADDRESS

____________________________________________________

CITY/STATE/ZIP

____________________________________________________

AGENT/REPRESENTATIVE

____________________________________________________

PHONE (Area/Number/Extension)

To offer:

B.(PRODUCT/SERVICE)

Section 125 Eligible

______________________________________________ Yes [__] No [__]

______________________________________________

______________________________________________

______________________________________________

I further certify that the above named company applicant has provided evidence of having met and/or exceeded all requirement of R.S. 42:455; has knowledge of the requirements of the rule governing payroll deductions; and that this department/agency attests that this product/service would be a benefit for employees of this department/agency.

Department ____________________________________

Signature ______________________________________

Title _________________________________________

Date __________________________________________

La. Admin. Code tit. 4, § III-139

Promulgated by the Office of the Governor, Division of Administration, Office of State Uniform Payroll, LR 12:763 (November 1986), amended LR 16:402 (May 1990), LR 19:318 (March 1993), LR 22:22 (January 1996), repromulgated LR 26:1033 (May 2000), amended LR 32:91 (January 2006).

AUTHORITY NOTE: Promulgated in accordance with R.S. 42:455.