NSU Employee Gift Payroll Deduction Form
Thank You!
Check one: [ ] New Pledge [ ] Increase Pledge Amount [ ] One-time Deduction
N#:_______________Title:______ First Name: _____________________ Last Name: ________________________
Phone Ext.: ___________ NSU email: ________________________ Personal email: __________________________
Total Pledge Amount: $___________.___ Per Pay Deduction Amount: $_________.___
Per pay period deduction: $1.93 = $50/year, $3.85 = $100/year, $9.62 = $250, $19.24 = $500, $38.47 = $1,000/year*
[ ] I want to create a Changing Lives Scholarship (CLS)*
*Pledging $5,000 total or $38.47 per pay deduction for five years allows you to name a Changing Lives Scholarship. Complete
and attach the naming and term form. Changing Lives Scholarship donors also are President’s Associates.
Auto Renewal: [ ] Yes (Auto-renew) Initials: ___ __ [ ] No
Please direct my gift to: [ ] NSU Fund (Greatest Need/Scholarships)
[ ] Specific Colleg
e/Center/Program ___________________________________________
Additional Instructions: _
I understand that my NSU paycheck stub, indicating my payroll deductions, will serve as my receipt.
________________________________________ ___________________
Signature (print form and sign) Date
[ ] You may incl
ude my name and pledge level in the Donor Honor Roll, NSU publications, press releases, and other
means of recognizing my support. [ ] You may include my name only for support recognition. [ ] Please do not publish
my name.
My name for recognition should appear: _____________________________________________________________
[ ] I have made a provision in my will for NSU. [ ] I would like to talk with someone about a planned gift.
For Shared Services/Payroll Use Only:
Deduction Code:
__________ Start in Pay #/Year: ________________ End in Pay #/Year: ________________
__________________________________________ ________________________________________
Shared Services Entry / Date Payroll Audit / Date
For Advancement Services Use Only: Use Pay Period Start/End Dates Only
Pledge #: _________________ Pay Period Start: __________________ Pay Period End: __________ _________
Pay Day Start: _____________ Auto Renew: [ ] Yes [ ] No (If “No”, provide Pay Period End) [ ] Cancel Pledge
[ ] This is an additional pledge. Per Pay Deduction Amount is now $_________.___
Approved by: ____________________________________________ _______ ______
Advancement Service Representative (print name) Extension
Please print to physically sign this form, then return your completed form ATTN: Raphael Walters, Division of Advancement
and Community Relations [Email scanned forms: rwalters1@nova.edu Fax: 22514 Interoffice Code: AVCR (Advancement)]
Last Updated: 8/21/2018
