Payroll Deduction Card

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: ____________________________ __________________________________
                                     Last                                             First

|__|__|__| |__|__| |__|__|__|__|
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 7/2011