PAYROLL DEDUCTION AUTHORIZATION FORM
Mercer University Employee ID#:
Title Department
o College of Health Professions
o College of Liberal Arts
o College of Pharmacy
o Eugene W. Stetson School of Business
o Georgia Baptist College of Nursing
o McAfee School of Theology
o
College of Professional Advancement
o School of Engineering
o School of Medicine
o Tift College of Education
o Townsend School of Music
o Walter F. George School of Law
FUND(S) I WISH TO SUPPORT (When selecting more than one fund please designate the amount to each fund.)
o
General University Support
o Athletic Foundation
o Baptist Scholars
o McDuffie Center for Strings
o Mercer On Mission
o Mercer University Press
o Parents Fund
o Grand Opera House
o Tarver Library
o Swilley Library
o Law Library
o Medical Library
SCHOOLS OTHER LIBRARIES
o Other Program ___________________________________________________________________________________
I wish to support the University and hereby authorize
the payroll office to deduct from my monthly
paycheck the following contribution:
$
x 12 Periods
$
TOTAL
Chancellor’s Circle – $2500 ($208.34 monthly)
President’s Club – $1000 ($83.34 monthly)
Penfield Club – $500 ($41.67 monthly)
Spires Club – $250 ($20.84 monthly)
Towers Club – $100 ($8.34 monthly)
LEADERSHIP GIVING LEVELS (Calendar Year)
SIGNTATURE OF EMPLOYEE DONOR
Signature
EMPLOYEE DONOR/ame
Name
Deductions continue indefinitely.
To change your payroll deduction setup, please email
bate_ca@mercer.edu with the subject "Payroll Deduction"
and include the relevant information to discontinue or to
change the fund(s) and/or amount(s) of deduction.
Special Instructions:
PAYROLL DEDUCTION DETAILS
Pursuant to the Revenue Reconciliation Act of 1993, no goods or services are provided to you. Mercer University's federal identification
number is 58-0566167. The fiscal year is July 1 to June 30. Refer to your payroll check stub for your total contributions.
(New or additional deduction?)
Date
Begin my payroll deductions on this date*:
*Please note, payroll is processed before the last day of the month. To ensure your gift is processed in the same month as your form is submitted,
please submit your form before the 15th of the month.
PLEASE RETURN COMPLETED FROM TO:
University Advancement
Chrystal Bate
Director of Advancement Services
bate_ca@mercer.edu
New Setup (I want to start a payroll deduction gift.)
click to sign
signature
click to edit
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