Payroll Deduction Gift Form

Payroll Deduction Gift Form
Please select
USU Area to Support
To contribute through payroll deductions, there is a minimum of $1.50 per pay period per area you wish to support and a minimum of 3 months per deduction.
USU Area to Support
Other Area to Support
Gift Instructions
Deduction Amount (per pay period)
Duration of Deduction
Please enter number of payments
When this pledge is fulfilled, would you like to be contacted about continuing the payroll deduction?
Renew Contact Date

MonthDayYear
Change or Removal of Existing Deductions
Please tell us how you would like your current deductions changed, or tell us what deductions you would like to remove.
Additional Comments or Notes
Please tell us any special needs you may have on your payroll deduction.
Contact Info
Name

First NameLast Name
A Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Campus Contact Info
Department
UMC or Statewide Campus Address
Campus Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Should be Empty:

Contact Info