LAC 4: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 __________________________________________