Faculty Staff Payroll Deduction Form

							                            Faculty & Staff Payroll Deduction Form
                                                        Donor Information
      First Name:__________________________ Last Name: ___________________________                       MI:____
     Address:__________________________________________ Phone Number:________________________
     Department: _________________________________                    Campus Phone:_____________________________

                                                            Gift Information

Gift Designation:
Please direct my gift to:
_____ My area of choice (please specify):_______________________________
_____ Where the need is greatest


Payroll Deduction:
                         START                    CHANGE          My deduction to the NIU Foundation
  Employee Type:         Salaried       Hourly
  Effective Date: _____________
  Amount to deduct each pay period: ____________
NOTE: Any authorization to withhold from the salary or wages of an employee shall terminate and such withholding
shall cease upon the happening of any of the following:
    1. Termination of employment
    2. Written notice by the employee of cancellation of such former authorization
Employee ID*:______________                                    Signature: _______________________________________
*Employee ID can be found on your check or payment advice



                                    Please return this form via campus mail to:
                                               Advancement Services
                                                 Swen Parson 220




                                                                                                              800505