Mt. San Jacinto College Foundation
PAYROLL DEDUCTION FORM
Name: ___________________________________________ Employee ID: _______________________________
Home Address: __________________________________________________________________________________
Email: ____________________________________________ Home Phone: _______________________________
H
OW ARE YOU PAID: HIRED CATEGORY: PAYROLL SKIPS:
Once/Month Certified Faculty July
Twice/Month Classified August September
Start Date Amount of Deduction Total Payroll Deduction
Of Deduction Each Pay Period $__________ Requested $____________
(
$5 or above)
PAYROLL DEDUCTION AUTHORIZATION
I authorize the payroll deduction shown above. I understand that the Payroll Deduction I am enrolling in does not replace any current
payroll deduction that is in place. I understand this authorization shall remain in effect until revoked by me in writing. I understand
that if I revoke this Payroll Deduction all funds previously deducted from my payroll will become a donation to the Foundation and
are non-refundable. I understand that payroll deduction is voluntary. By signing below, I acknowledge that this authorization is made
voluntarily, that I have received a copy of this authorization, and I agree to its terms and conditions.
E
MPLOYEE’S SIGNATURE: ________________________________ TODAY’S DATE: _________________
Start
Change
Stop
Location ___________
Fnd. Employee Initials: ____________
Date: ______________
For Office Use Only
$_________ President’s Club $_________ Eagle Athletic Club
$_________ Department ____________________________________
$_________ SGA/Club _____________________________________
$_________ Scholarships/Memorials __________________________
$_________ Other ________________________________________
click to sign
signature
click to edit
![]()
