Payroll Deduction Form

Thank you for signing up for Payroll Deduction. If it is your first time signing up, please fill out the form below in its entirety. To easily increase or decrease your current payroll deduction, please fill out this form again with the new amount. Your existing amount will be replaced by your update here, effective on the start date selected. To terminate your payroll deduction, please contact HR directly at 410.337.6069.

If you see this don't fill out this input box.

First name *

Last name *

Department or office

Email *

Name as you would like it to appear for recognition purposes

Please direct my gift to *

Greater Goucher Fund (current priorities)

Other

If other, please specify

Make my gift in honor or memorial of

Why I am honoring this person/these people

Payroll deduction (amount per pay period) *

$10

$15

$25

Other Amount

The selected amount will be deducted from each paycheck depending on your pay period: Monthly, Bi-weekly or weekly

If other amount, please specify

Start payroll deduction (month/year) **Payroll deduction will continue to be withdrawn from your paycheck until you let Human Resources know that you would like it to stop

This gift is anonymous

Yes

Signature *

Confirm signature *

Check here to confirm that typed name on signature line serves as electronic signature.

All questions should be directed to Alison Schiller, Assistant Director of Annual & Affinity Giving, at 410-337-6292. Gifts through payroll deduction will receive a gift receipt in January of each year.

Thank you for your regular payroll contribution to Goucher College!