Payroll Deduction Authorization Form (For State Of California Employees)

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The Fresno State Annual Fund
California State University, Fresno
University Advancement (KEATS BLDG.)
5244 N Jackson Ave KC 45
Phone: 278-4036/ Fax: 278-7925
Payroll Deduction Authorization Form
(for State of California employees)
Please complete and send original to UNIVERSITY ADVANCEMENT (Keep a copy for your records)
I. DONOR INFORMATION
Last name:
First name:
M.I.:
Address:
Social Security Number:
Phone:
Home
Office
City/State/Zip:
Fax:
E-mail:
II. EMPLOYMENT INFORMATION
Job Title:
III. DONATION INFORMATION
SELECT DEDUCTION INFORMATION BELOW:
IV. GIVING TO FRESNO STATE
School/unit:
X____________________________
Account name:
Account number:
X____________________________
x_____________________________
V. DEDUCTION INFORMATION
Pay Period:
Deduction
Organization
Type (Please check ONE Box)
(Office use only)
Deduction Amount:
Code:
Code:
089
028
$4.17/month ($50.04/year)
New
Month
Year
$8.34/month ($100.08/year)
Delete
(to delete an existing
$20.84/month ($250.08/year)
payroll deduction):
$41.67/month ($500.04/year)
Specify:___________________
$64.50/month ($750.00/year)
Change
(to change an existing
$83.34/month ($1,000.08/year)
payroll deduction):
$208.34/month ($2,500.08/year)
Specify:___________________
$416.67/month ($5,000.04/year)
VI. AUTHORIZATION
I hereby authorize the state collector to deduct from my salaries and wages the amount specified now and in the future for payment
of the above contributions to California State University, Fresno.
This authorization will remain in effect until cancelled by me or by California State University, Fresno Foundation.
I certify I am an employee of California State University, Fresno and understand that termination of employment will cancel all
dedications made under this authorization.
Signed:__________________________________________________ Date:___________________________________
For office use only
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