UCSD PAYROLL DEDUCTION AUTHORIZATION FORM



UCSD PAYROLL DEDUCTION AUTHORIZATION FORM

For faculty/staff members of the University of California, San Diego

Please return this form to:

UCSD, Gift Processing Department, Mail Code 0940

For more information call Sandra L. Stewart at x44493

EMPLOYEE (RECORD GIFT FROM):

Name______________________________________________ Employee ID#______________

Please print – Last, First, Middle

Address____________________________________________ Telephone__________________

Street or Campus Mail Code

____________________________________________ E-mail_____________________

City, State, Zip

My monthly payroll deduction and tax-deductible contribution will be:

___$1 ($12 total annual contribution) ___$25 ($300 total annual contribution)

___$5 ($60 total annual contribution) ___$100 ($1,200 total annual contribution)

___$10 ($120 total annual contribution) $_______ Monthly Deduction Amount

I authorize the Accounting Office/Payroll Division to deduct the above noted amount from my monthly earnings and credit it to the UC San Diego Foundation, Fund #xxxx:

My deduction should begin effective with the month/year _______________, and continue until I terminate it OR Begin date:_______________ End Date:__________________.

Signature________________________________________Date___________________________

**Please note: In accordance with IRS regulations, the estimated average fair market value of benefits received is $xxx per annual gift. If you choose to decline receiving benefits, your gift is fully tax deductible. Please check the box below to decline benefits:

( I would like to decline receiving benefits.

For Payroll/Accounting Use Only:

Loc

|Emp#

|Annual Amt

|Deduction

Amt. Code

|Period

Start Date

|

End Date

|

|

| | |

Note: This authorization can be adjusted or canceled anytime upon your request. 1977 California Information Practices Act Disclosures: UCSD maintains charitable giving information on its donors in a database maintained in the Advancement Services Department. Limited personnel at UC San Diego have access to the database and use the data in the regular course of their business at UC San Diego. Furnishing the information is strictly voluntary and will be maintained confidentially. The information may be used by other University departments in the regular course of business, but will not be disseminated to others except if required by law. You have the right to review your own data file. Inquiries should be forwarded to the Chief Financial Officer, Advancement Services Department, UC San Diego Foundation, 9500 Gilman Drive, La Jolla, California 92093-0940.

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