Payroll Deduction Form

1

Thank you for initiating a payroll-deduction gift!

If you prefer to make a one-time gift instead, please click HERE.

IMPORTANT:

This payroll deduction form should only be used for gifts to Western Illinois University and programs supported through the WIU Foundation. Do not include SECA or any other non-University gift deductions.
Your payroll deduction gift(s) will be based entirely on the information provided on this form.
Gift processing personnel may contact you if clarification is needed.

2

Your Name* This field is required.

First Name

Middle Name

Last Name

3

Employee ID #* This field is required.Your 9-digit employee ID number (no dashes)

4

E-mail* This field is required.Please use wiu.edu email address

example@wiu.edu

5

Campus Phone

Area Code

Phone Number

6

Please indicate your gift amount(s) and designation(s).* This field is required.Click "SAVE" after each line. Click "NEXT" to proceed to next screen.

7

Indicate payroll type:* This field is required.

Monthly

Semi-Monthly

Bi-Weekly

8

This pledge is:* This field is required.

A new payroll deduction pledge (first-time payroll deduction gift)

An additional payroll deduction (adding an additional payroll deduction gift)

A change in an existing pledge (an adjustment to the amount of an existing pledge)

9

Terms and Conditions* This field is required.I understand that this authorization shall remain in effect until revoked by me, allowing me to meet payroll deadlines in order to make effective any payroll record changes in this assignment. This authorization will continue in effect until termination of my employment with Western Illinois University or until I submit written notice of cancellation with the WIU Foundation. Change or cancellation of this authorization must be made in writing.

10

Signature* This field is required.I hereby authorize and request the State of Illinois - Western Illinois University to deduct the amounts I have designated on this form from my paycheck each pay period, and to remit the withheld amount(s) to the Western Illinois University Foundation.

11

Today's Date

Date