Fillable Payroll Deduction Form LSU FOUNDATION PAYROLL DEDUCTION FORM

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Payroll Deduction Form LSU FOUNDATION PAYROLL DEDUCTION FORM

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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
___________________________________
______________________
______________________
___________________________________
______________________
______________________
To
tal $____________ 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 3796 Nicholson Drive Baton Rouge, LA 70802 Attn: Monica Derozan
For Foundation Use Only:
APPROVED
Date___________
Initials__________
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Payroll Deduction Form LSU FOUNDATION PAYROLL DEDUCTION FORM

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Completed 8 April 2020

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