Please note that this form needs to be completed and submitted no later than the sixth week of each semester that you would want to participate in this plan.  

For more information, please visit our website.

* Name (Last Name, First Name)

* RU ID Number

* Employee ID Number

* Phone Number

* Employee Type

* Semester


* Deduct For:


* By checking the box below, I authorize Rutgers University to deduct from my biweekly salary or stipend the full semester fee owed by me for those items listed above.I understand that if I should leave the University or resign my appointment, the entire unpaid account balance shall become due immediately and payable without formal notice or demand. If the balance remains unpaid and the University refers this account to an outside collection agency, I agree to pay all collection costs. I further understand that if the balance is unpaid, a HOLD will be placed on my records and no transcripts will be issued until this debt is paid in full. No change of this agreement between the University and myself will be binding unless it is done by a mutually executed document. I agree to be responsible for any collection costs/fees incurred in the event my account is sent to collections as per the University's Financial Responsibility Agreement Statement.