Mt. San Jacinto College Foundation
PAYROLL DEDUCTION FORM
Pledge for Success
Name: ___________________________________________ Employee ID: _______________________________
Home Address: __________________________________________________________________________________
Email: ____________________________________________ Home Phone: _______________________________
H
IRED CATEGORY: Administration Faculty Classified
Start Date Amount of Deduction
Of Deduction Each Pay Period $7 $35 $70 $_________
Other Deduction: LGBTQ+ Undocumented Students Food 4 Thought Other ________________
Amount of Deduction Each Pay Period $__________
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.
EMPLOYEE’S TODAY’S
S
IGNATURE: _______________________________________ DATE: _______________________
To Be Completed by Payroll
Date form Received: ____________________________ Start Date of Deduction:
____________________
Total Amount to be Deducted: $__________________
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