Payroll Deduction Form
Name _____________________________________________________
Department ________________________________________________
Address ___________________________________________________
City / State / Zip ____________________________________________
Phone ___________________ Email ___________________________
I authorize Daemen College to deduct $__________ from
my paycheck for ________ (#pay periods), beginning on
___________ (date).
TOTAL ANNUAL GIFT:
GIFT DESIGNATION:
r Annual Fund
r Other
Signature _________________________________ Date ___________
OR MAKE A ONE-TIME GIFT:
❒ My check in the amount of $ ___________ is enclosed.
Please send to: Office of Institutional Advancement, Daemen
College, 4380 Main St., Amherst, NY 14226-3592.
❒ Please charge my credit card for my gift
MasterCard / Visa / Discover
Card # ____________________________________________________
Exp. Date _____________________ 3 Digit Security Code ________
Signature _________________________________ Date ___________
$ x =
$
$ x =
$
$ x = $
$ x = $
$
x = $
$ x =
$
$ x = $
$ x = $
Amount
Deducted
# of Pay
Periods
Total Tax
Deductible
Contribution
For more information please
contact Meghan Kloss ’15,
Director for Annual Giving
(716) 839-7263 or
mkloss@daemen.edu.
