<p> Payroll Deduction Authorization City of Regina Transit Pass</p><p>Check one only ( X )</p><p>Monthly deduction amount $76.67 (for employees who are paid monthly)</p><p>Biweekly deduction amount $35.39 (for employees who are paid bi-weekly)</p><p>Employee Name: </p><p>Employee Number: </p><p>Ministry: </p><p>Effective Date: </p><p>Sign this form authorizing payment by payroll deduction for a City of Regina transit pass.</p><p>I hereby authorize payroll deduction for a City of Regina transit pass. I understand that this deduction authorization is in effect for a minimum of six month. I understand that if the purchase includes one or more adult dependents, the amounts above will increase.</p><p>Signature: ______Date: </p><p>Please become familiar with the Terms and Conditions by visiting the City of Regina’s website at http://www.regina.ca/Page618.aspx</p><p>Routing: Send completed form to: Employee Service Centre 2100 Broad Street Regina, SK S4P 1Y5</p><p>Payroll Deduction Authorization – City of Regina Transit Pass Form 03-Feb-2017 Page 1 of 1</p>