NOT FOR ONE-TIME PAYMENTS
Note: Payroll deductions will be taken from January through December. Please print this page, complete the required information, and forward it to the Office of University Human Resource Services.
Printed Name: ____________________________ __________________________________
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BSU Identification Number
Signature: ____________________________________________ Date: ________________
I authorize Ball State University to make the following deduction from my payroll
check for remittance to the United Way of Delaware County.
Deduct $ __________ per pay, until a total pledge of $ _____________ has been met.
I am paid: [__] Bi-Weekly [__] Monthly.
Annual campaign deductions will start with the first check received in January.
____ Check here to stop an authorization after it has been submitted for the campaign year.
Deduction Code: 320. Form PEB 20. 5/2003. Rev 8/2014
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