Fillable Payroll Deduction Form Food Pantry LSU FOUNDATION PAYROLL DEDUCTION FORM

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Payroll Deduction Form Food Pantry LSU FOUNDATION PAYROLL DEDUCTION FORM

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For Foundation Use Only:
APPROVED
Date __________
Initials ________
______________________________ _____________________ __________________
_________________________________________________________________________
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LSU FOUNDATION PAYROLL DEDUCTION FORM
Dear Contributor:
If you wish to make a single annual contribution to the LSU Foundation
through a payroll deduction, please check “Single Annual Contribution” and complete
the first section. If you prefer to make your contribution as a continuing payroll
deduction, please check “Continuing Payroll Deduction” and complete the second section. For
information about the eligibility of your contribution for corporate match, please contact the Gift
Processing Supervisor at the LSU Foundation, at 578-3811.
I, ____________________________, hereby authorize my employer, until further notice
(Print Employee Name)
from me in writing, to deduct the following amounts from my paycheck.
(Employee Signature) (LSU ID#) (Date)
Employee Address:
(Street Address) (City, State) (Zip Code)
************************************************************************
Single Annual Contribution
Changing from $_______per year to $_______ per year
Account Name or Project ID/ Account #
Amount
Effective Date
Total $____________ This amount will be deducted from the next pay check processed.
************************************************************************
Continuing Payroll Deduction
Changing from $_______per pay period to $_______ per pay period
Account Name or Project ID/ Account #
Amount
Effective Date
Total $____________ This amount will be deducted from each pay check processed, beginning
with the next paycheck.
For Foundation Use Only:
APPROVED
Date___________
Initials__________
Return this form to: LSU Foundation 3838 West Lakeshore Drive Baton Rouge, LA 70808 Attn: Monica Derozan
LSU Food Pantry Support Fund
LSU Food Pantry Support Fund
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Payroll Deduction Form Food Pantry LSU FOUNDATION PAYROLL DEDUCTION FORM

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Completed 18 April 2020

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