Payroll Deduction
Authorization
Form
This form is used by donors to make contributions to The
Mississippi Delta Community College Development Foundation,
Inc. to support the programs and/or scholarships as indicated
below. This form authorizes the MDCC Foundation to deduct
from a College employee’s pay an amount as reported below.
DONOR CONTACT INFORMATION
Donor’s Name:
Address:
Cell Phone:
E-mail:
Work Phone:
CONTRIBUTION INFORMATION
Monthly Amount to be Contributed: $
First Month of Contribution:
Please designate the fund(s) or program(s) you would like to support by checking the box or boxes below:
Annual Fund (scholarships and capital improvements) % or $
Athletic Improvement Fund (supports all areas of athletics) $
Steinriede Faculty Development Fund $
Emergency Student Support Fund $
Other $
(note: if checking “other”, please indicate the specific fund name. A list of all funds can be obtained from the Foundation.)
SPECIAL INSTRUCTIONS
Check this box if you wish to remain anonymous and not listed as a contributor in publications.
SIGNATURES
I hereby authorize Mississippi Delta Community College and the MDCC Development Foundation, Inc. to initiate a
payroll deduction based on the information above. I understand that monthly deductions will continue until
f
ur
the
r
notice and that I can cancel it at any time by notifying the College or the Foundation in writing.
Donor Date MDCC Foundation Representative Date
PLEASE RETURN THIS FORM TO THE MDCC
FO
U
N
DA
TION
Mississippi Delta Community College Development Foundation, Inc.
P.O. Box 710 | Moorhead, MS
38761-0710
T: 662-246-6274 | E-MAIL: jaycock@msdelta.edu |
www.msdelta.com
The Mississippi Delta Community College Development Foundation, In. is a 501(c)(3) organization.
Gifts are deductible to the extent of current IRS
regulations.
City, St
