Mt. San Jacinto College Foundation
PAYROLL DEDUCTION FORM
Pledge for Success
Name: ___________________________________________ Employee ID: _______________________________
Home Address: ________________________________________________________________________________
Email: ____________________________________________ Home Phone: _______________________________
HIRED CATEGORY: Administration Faculty Classified
Pledge for Success $7 $35 $70 Other: $_______
Student Success Funds: LatinX $______ LGBTQ+ $_______ Black/African American $______
Other Deduction: President’s Club $_______
Start Date of Deduction: ____________ Total Amount of Deduction Each Pay Period: $_________
PAYROLL DEDUCTION AUTHORIZATION
I authorize the payroll deduction shown above. I understand that the Payroll Deduction I am enrolling in does not replace any
current payroll deduction that is in place. I understand this authorization shall remain in effect until revoked by me in writing. I
understand that if I revoke this Payroll Deduction all funds previously deducted from my payroll will become a donation to the
Foundation and are non-refundable. I understand that payroll deduction is voluntary. By signing below, I acknowledge that this
authorization is made voluntarily, that I have received a copy of this authorization, and I agree to its terms and conditions.
EMPLOYEE’S TODAY’S
SIGNATURE: _______________________________________ DATE: _______________________
To Be Completed by Payroll
Date form Received: ___________________________ Start Date of Deduction: ____________________
Total Amount to be Deducted: $__________________
