Payroll Deduction Form

Please fill out the form below to set up your payroll deduction.

Name:

Street:

Street2:

City:

State:

Zip:

Phone Number:

Campus Email:

Last 4 digits of your Social Security Number (for verification purposes, form will not be processed without it):

Click here to see a list of fund areas.

Fund Area:
--Select-- Fund for Excellence Other

Fund Area 2:
--Select-- Fund for Excellence Other

Fund Area 3:
--Select-- Fund for Excellence Other

If you choose "other", please type the designation here:

Payroll deduction amount per pay period ($2.50 minimum):
$

Please choose ONLY ONE of the following:

I authorize the MSU Foundation to deduct the above amount each pay period for this period of time:

Beginning Date Ending Date

OR

I authorize the MSU Foundation to deduct the above amount each pay period until I provide instructions to stop (automatic renewal):

Please Initial: