C&PS: Faculty/Staff Ticket Payroll Deduction Request Form

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Faculty and Staff Parking Ticket Payroll Deduction Request Form

This form is for current Cornell faculty and staff only.

By filling out this form current regular full- and part-time faculty and staff of Cornell University are requesting that Commuter and Parking Services send your parking fine to the Payroll Office. We will receive payment for your fine(s) through payroll deduction.

Please fill in all fields of this form or we will be unable to process it.

Information About You:

Your Name:

Phone:

Cornell ID# :

NetID:

Information About Your Car:

License Plate Number:

State/Province:

Ticket Information

Please list seperately all tickets you would like to pay through payroll deduction.
Please include the late fee for each ticket you are paying beyond 21 calendar days after the ticket was issued.

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

TOTAL AMOUNT: $

Payment (please click the "calculate" button above)

I owe Cornell University $ for violations of campus parking rules and regulations. I voluntarily request that Cornell deduct the parking fine(s) listed above from my wages according to the listed schedule. I acknowledge that the fine was determined in a manner consistent with Cornell procedures for the adjudication of parking violations, and that I was given the opportunity to use these procedures. This authorization does not give Cornell any additional claim or right to the amount due.

I understand that the payroll deduction option is available for my benefit and convenience and that I may revoke this authorization at any time and that such right may not be waived.

I further understand that deductions will be taken from my paycheck according to the following schedule:

Amount due
Minimum deduction amount

$0 to $50
$20 per pay period

$50.01 to $200
$40 per pay period

$200.01 to $500
$50 per pay period

$500.01 and above
$100 per pay period

Please note: If the amount due is less than the minimum deduction amount, the full amount due will be deducted.

My Payment Schedule:
Please deduct $ per paycheck.

Signature:

By checking the "agree" box, I am signing this form and agree to all terms described above. My signature certifies that all statements on this form are correct. All of this information is true and accurate to the best of my knowledge; I understand that the payroll deduction is only an optional payment plan and does not affect my obligation to pay the entire amount due. Neither revocation of this authorization nor termination of my employment at Cornell University relieve me of my obligation to pay the remaining balance.

Agree

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