University of West Georgia Faculty/Staff Gift Form
USE FOR PAYROLL DEDUCTION PLEDGE LIMITED TIME ONLY
DONOR/EMPLOYEE Information:
Mr. / Mrs. / Ms. / Dr. (circle one)
Employee First Name
Middle Name
Last Name
Is gift to
be credited to spouse/partner also? Yes
No
(if yes, please provide name)
Last Name Middle Name Spouse/Partner First Name __________________ ________________ __________________
Home Address:
Primary Phone: Other Phone: UWG Email User ID:
Campus Address: Department:
Title:
PAYROLL Instructions for Non-Recurring gifts:
I/we support UWG with a gift of $ to be paid via payroll deduction each pay period for pay periods.
I am a: 10 month employee 12 month employee bi-weekly employee
UWG Employee ID#
Payroll Deduction Notice: Your payroll deduction will begin with the next pay cycle deadline after which your completed form is
submitted. You must sign this form to authorize this charitable gift payroll deduction, and to be compliant with IRS regulations.
10-month Employee Notice: Please contact Dale Duffey at extension 94106 or dduffey@westga.edu to review number of pay
periods and deduction amounts before submission to payroll.
GIFT Information:
Gift made in honor / memory (circle one if applicable) of
Gift of $ is to UWG Foundation HelpWest Fund or as follows:
UWG College, Division or Department $
UWG Other $
I hereby authorize the University of West Georgia to deduct, in accordance with University Policy, the amount designated above
from my paycheck each payroll period, and to remit those amounts to the University of West Georgia Foundation, Inc. Any changes
to these payroll instructions must be received in writing in the Human Resources Office no later than 12 working days prior to the
distribution date for that paycheck. I understand these payroll deductions will continue indefinitely until I notify Human Resources
to stop them, or they are automatically stopped due to changes in my employment status with UWG.
Signature of Employee: Date:
click to sign
signature
click to edit
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