Faculty and Staff Payroll Deduction

Please print the following information:

Name: _____________________________________

Home Address: ____________________________________

____________________________________

I authorize the deduction of the following amount of $ _______ per pay period from my paycheck, to be contributed to the State University College at Oneonta, effective immediately or on the following date _________. This authorization will remain in effect until changed or canceled in writing.

____ This gift is a change from my current payroll deduction.

____ This gift is a new payroll deduction.

Gift Designation: ___ Unrestricted Endowment

___ Alumni Annual Fund (for faculty/staff who are also alumni)

___ Other (Please list scholarship or fund name)

_____________________________________________

Signature: _______________________________________________

Date: _______________