HSD Education Foundation Payroll Deduction Form

Payroll Deduction Form
I authorize Harrisburg School District to withhold from my wages $  Amount per pay period which shall be the total amount of $   Total Amount per year for the purpose of contributing to the Harrisburg Education Foundation.

Of this contribution, I choose:

Enter % (e.g. 25)%  = $  to go to the Annual Fund and/or
Enter % (e.g. 75)%  = $   to go to the Endowment Fund.
____________________________________________________
Percentage Must Equal 100%
I further agree that in the event my employment shall terminate, either voluntarily or involuntarily, my wage withholding will cease upon my final paycheck, or until I request cancellation.

I represent that this authorization is executed voluntarily and has not been made as a condition of my continued employment.
Name*

First NameLast Name
Employee's Email Address*
example@example.com
Home Building*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Phone Number*
Please enter a valid phone number.
I prefer NOT to be recognized publicly as a donor on the HSD Education Foundation website.

Yes
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty: