Authorization for Payroll Deduction for Meal Card Debit Plan UVA Medical Center Employees (Agency 209 payroll) Only
Name___________________________________________________________________________ Employee 9 Digit ID#______________________(located on the back of UVA ID Badge) Department ________________________________________________________________________ Work Phone # ____________________Home Phone #_________________________ Total to be deducted each payroll period: $ ______ ($10.00 minimum/$125.00 maximum) Your signature will authorize the above amount to be added to your ID badge and deducted from your payroll check(s) as indicated. Your signature will also indicate that you accept the following conditions for using Meal Card Debit Plan: 1. A 5% rebate will be added to your Meal Card Debit balance with each payroll deduction. Example: Payroll deduction equals $10.00; Card Balance updated for $10.50 (5% of $10.00). 2. Changes to your Payroll deduction are limited to two times per calendar year and will require completion of a new authorization form. A change would be to: Terminate your deduction Re-activate your deduction 3. If you have an unused balance in the Meal Card Debit Plan when you leave the employment of the Medical Center, you may apply for a refund through Nutrition Services by calling 924-2696 or 982-0240. (Refund will not include 5% rebate applied to your account). 4. You will be responsible for any charges made to your account, so please report a lost ID badge immediately to the ID Badge Office at 982-4009. 5. It is your responsibility to know the balance remaining in your account. 6. You cannot redeem your Meal Card balance for cash. Signature ________________________________ Date________________________________ AFTER COMPLETING AND SIGNING THIS FORM, FAX IT TO MEDICAL CENTER PAYROLL AT 3-6095. FORMS CAN ALSO BE DROPPED OFF AT THE PAYROLL OFFICE AT 1222 JPA, ROOM 2218. KEEP A COPY FOR YOUR RECORDS. Call the Payroll Office at 924-9854 or Nutrition Services at 924-2696 if you have questions about the payroll deduction Plan. You will be able to use your ID badge for purchases on the Friday of your first payroll deduction to purchase food or beverages at the following locations: East Cafeteria, Wahoo West Café, KCRC Cafeteria, Higher Grounds (East Cafeteria), Outtakes Kiosk across from Claude Moore Health Sciences Library