Payroll Deduction Form

Western Washington University
Payroll Deduction Pledge Form

Please Print and mail/fax to:
The Western Washington University Foundation Old Main 430 / Mail Stop 9034
(360) 650-3027 fax (360) 650-2832

Donor Information

Name (Last, First, Middle)__________________________________________________________
Western ID Number_________________ Date of Birth __/__/__
Department Name and Address_____________________________________________________
Mail Stop_________ Campus Phone__________________

Gift Designation

__Campus Enrichment Fund
Please accept my/our gift to provide unrestricted support for the university's greatest needs.

__Specific Fund(s) I wish to support the following areas:

College of: _________________________________________________________________________
Department of: ______________________________________________________________________
Scholarship Fund (please specify): ___________________________________________________
Program (please specify): _____________________________________________________________

Payment Schedule

Purpose of gift or Fund name(s)	Deduction Amt (each paycheck)	Number of annual pay periods (circle one)	Total Annual Commitment
__________________________________	$______	x 24 pay periods (12 mos.) 18 pay periods (9 mos.)	= $______
__________________________________	$______	x 24 pay periods (12 mos.) 18 pay periods (9 mos.)	= $______
__________________________________	$______	x 24 pay periods (12 mos.) 18 pay periods (9 mos.)	= $______
($5 minimum deduction per pay period) TOTAL:	$______		$______

I wish to support the above named funds via payroll deduction to The Western Washington University Foundation . I have marked the amount to deduct for each fund during each pay period (twice each month), and have calculated the total annualized amount for each. I understand that my annual commitment will be automatically renewed each year until I instruct The Western Washington University Foundation otherwise. I understand that I may alter my commitment amounts or change the restriction of my pledge at any time.

Signature of Donor

Signature_______________________________________ Date_________________

Gift Processing Information (for adis use only)