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.
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