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CHRISTMAS CLUB SAVINGS ACCOUNT (CCSA)
AUTHORIZATION AGREEMENT / WAIVER
VOLUNTARY BENEFIT AVAILABLE FOR FULL TIME EMPLOYEE ONLY!
Indicates required field
I hereby authorize Southern Medical Corporation "SMC" to initiate a payroll deduction from my paycheck for the requested contribution to my Christmas Club Savings Account "CCSA". Additionally, I authorize SMC to apply these deductions as credit entries to my CCSA, which will earn no interest.
Rules to CCSA Membership:
Plan year runs from November through October
Employees can enroll at any time
Employees can enroll a maximum of once a plan year
Cancellation can be requested at any time, at which time the payroll deduction will cease. Cancellation must be written using this form indicating effective date of last deduction
Upon employment termination, the employee CCSA funds will be disbursed with the employee's last pay check
Upon deduction cancellation, the employee CCSA funds will not be disbursed until the first paycheck in NOVEMBER
SMC will disburse all CCSA checks along with the first paycheck in October of each year.
This deduction automatically renews at the end of each plan year, unless employee sends written notification as listed above.
This deduction authorization is to remain in full force through the plan year and automatically renew unless SMC has received written notification from me (employee) to cancel or change in such time and manner as to afford SMC a reasonable opportunity to act on it.
By clicking the box below, I am stating I understand and agree to the rules of the CCSA membership.
By checking this box and signing below, I am stating I understand and agree to the rules of the CCSA membership.
Form will not be submitted without checking this box.
Employee Name (as signature)
Your typed name here will represent your "signature"
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