Fillable Payroll Deduction Authorization (University of Wisconsin - LaCrosse)

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Payroll Deduction Authorization (University of Wisconsin - LaCrosse)

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The Payroll Deduction Authorization (University of Wisconsin - LaCrosse) form is 1 page long and contains:

  • 2 signatures
  • 4 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

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Payroll Deduction Authorization
Name(s)
Address
City/State/Zip
Campus Phone Email
YES, I would like to make a gift to support UWL students!
My total pledge/gift is $
Gift designation: Wherever it is
most needed (Unrestricted)
Restrict to:
Please accept my payment as follows:
Payroll deduction (complete below) Check enclosed (payable to UWL Foundation)
Credit Card (circle one) VISA MasterCard Am Express Discover
/
Card Number Exp. Date Sec. Code
Date
Cardholder
Signature Required
Payroll Deduction Authorization
Please deduct $ per pay period with an effective date of / /
EMPL ID #
(from earnings statement)
Signature:
Indefinite pledge New payroll deduction Replace existing deduction
THANK YOU FOR YOUR SUPPORT OF UW-LA CROSSE
The form requires your signature and must be submitted to the Foundation in hard copy.
This form will remain confidential. If you have any questions, please contact Kyle Slaby.
Kyle Slaby
Cleary Center 101B
UW-La Crosse Foundation, Inc.
615 East Avenue North
La Crosse, WI 54601
Email: kslaby@uwlax.edu
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Payroll Deduction Authorization (University of Wisconsin - LaCrosse)

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Completed 24 July 2020

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