CALIFORNIA STATE UNIVERSITY, CHICO
Charitable Gift Payroll Deduction Authorization Form
University Foundation
530-898-4488 | Zip 0155
University Affiliation (check one)
Please Check One or More:
I would like to have the following amount deducted from my paycheck to support California State
University, Chico: $______________ per month ($10 per month minimum)
I would like to change my current payroll deduction as follows:
Change deduction amount to: $______________ per month
Change designation(s): Please list the projects and amounts for each in the box below
A college/school/department/program. Please specify area and amount:
I would like to make an unrestricted gift to support the University’s greatest needs.
State Employee: I authorize the State Controller to deduct each month from my salaries and wages as specified. This
authorization will remain in effect until canceled by me or by California State University, Chico. I certify that I am an employee
of California State University, Chico, and I understand that termination of membership will cancel all deductions made under
this authorization. I will be called by a Gift Processor and asked for my SSN to be given to the State Controllers office.
Employee ID Number: __________________ Signature: _______________________________________________ Date: __________
Research Foundation Employee: I authorize the CSU, Chico Research Foundation to deduct the monthly
amount (one half each pay period) as specified. This authorization will remain in effect until canceled by me or
by the Research Foundation.
Employee ID Number: ____________________ Signature: _____________________________________________ Date: __________
Associated Students Employee: I authorize the Associated Students of California State University, Chico to
deduct the monthly amount (one half each pay period) as specified. This authorization will remain in effect until
canceled by me or by the Associated Students.
Employee ID Number: ______________________ Signature: _____________________________________________ Date:_________
Please return form to University Advancement Services, zip 0155. The University Foundation administers the University’s charitable gifts and is a
tax-exempt 501(C)(3) organization. One tax receipt will be issued at calendar year-end. If you have any questions, please call 530-898-4488.
Rev. 5/9/2019
