Payroll Deduction Authorization Form
Employee Name: _________________________________________________________________________________________________________ I am pleased to support UW-Stout and the Stout University Foundation with my gift commitment. Please withhold:
(check one option)
Other amount $______________________________________________________________________________________________ per pay period beginning with my next pay date. Please increase my current payroll deduction to $_________________________________________________________________________ per pay period beginning with my next pay date. Please accept my one-time gift of $_____________ payable by check. I wish to make my gift: Unrestricted 50% Unrestricted, 50% restricted to:________________________________________________________________________________ Fully restricted to:____________________________________________________________________________________________ Address:____________________________________________________________________________________________________ City:______________________________________________________________________________________________________ State: __________________ Zip:________________________________________________________________________________ Preferred Phone:______________________________________________________________________________________________ Campus Office Phone:___________________________________________________________________________________________ Preferred Email Address:__________________________________________________________________________________________ I hereby authorize the UW-Stout Human Resources Office to withhold the above stated amount from my regular payroll checks. The Stout University Foundation is the recipient of the indicated deduction. Annual acknowledgements of my gifts will be provided by the Stout University Foundation at the end of the calendar year. Signature:___________________________________________________________________________________________________ Date:______________________________________________________________________________________________________ I will notify the Foundation Office when I wish to alter this pledge.
Be An INSPIRATION.............................Mail your completed, signed form today to:
Stout University Foundation, Inc. Louis Smith Tainter House 320 South Broadway Menomonie, WI 54751 (p) 715-232-1151 ▪ (f) 715-232-5015 • www.uwstout.edu/advancement