Chemeketa Community College Foundation
Dear Chemeketa Employees,
Please join us as a monthly sustaining donor of Chemeketa Scholarships and Student Assistance Funds.
Your gift to the Chemeketa Foundation offers students a life-changing opportunity. Thank you for your support of Chemeketa students and programs.
Name: ______________________________________________ Campus phone: ___________ K#: ____________________
No action is necessary to continue current contributions. Please contact the foundation for changes to your contributions at any time throughout the year.
Please use this form to:
☐ Add a new monthly payroll deduction
☐ Increase an existing payroll deduction to the new amount indicated below
Amount of Deduction:
☐ $100 per pay period ☐ $40 per pay period ☐ $15 per pay period ☐ $5 per pay period
☐ $50 per pay period ☐ $25 per pay period ☐ $10 per pay period ☐ Other $ _______ per pay period
Please use my gift for the scholarship or fund indicated below:
☐ Apply to existing fund _______________________________________________ ☐ Unrestricted gift
(A list of funds is available at chemeketa.thankyou4caring.org/scholarship-list.)
I authorize my contributions to be made via payroll deduction. __________________________________
(Signature or type full name, if electronically submitted)
☐ I wish to remain anonymous. Your name will not appear in the annual donor report.
☐ I wish my gift to be recognized in honor or in memory of: ______________________________________________
(Please indicate if in honor or in memorial)
100% of every dollar goes to help students, no fees are charged to your gift.
Please complete this form and send to Chemeketa Foundation building 2, room 218. If you have multiple changes or deductions, please email detailed
instructions for your deductions to email@example.com. For questions, call the Foundation at 503.399.5148.
Your gift is tax deductible to the full extent allowed by law. Chemeketa does not provide goods or services in whole or partial consideration for any contribution
made to the organization by payroll deduction. All donations are subject to Chemeketa Community College Foundation policies. Your pay stub or a signed copy
of this form may be used for your tax purposes. Tax ID # 93-6097106