Louisiana Administrative Code
Title 4 - ADMINISTRATION
Part III - Payroll
Chapter 1 - Payroll Deductions
Section III-139 - SED-3 (01/06)
Current through Register Vol. 50, No. 9, September 20, 2024
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 __________________________________________
AUTHORITY NOTE: Promulgated in accordance with R.S. 42:455.
