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KENTUCKY STATE UNIVERSITY
Employee Donation Form
PAYROLL OFFICE USE ONLY
Amount per pay period $_____
Number of pay periods _____
Date of first deduction _____
Received on _____
Received by _____
Amount per pay period
Number of pay periods
Date of first deduction
Received on
Received by _____________________
Yes! I will participate in the Employee Campaign and it will send a strong message that I believe in Kentucky State University's mission!
Employment Category: Faculty Adjunct Faculty Full-Time Staff Part-Time Staff
the
will
message
Name___ KSU ID #___
KSU ID
Name
Address ___ City ___ State ___ Zip ___
State
Address
City
Zip
Email _____ Phone _____
Email
Phone
Department _____ Campus Phone _____
Department
Campus Phone
Check if you would like to be listed as "anonymous" in all donor recognition materials.
q Check if you would like to be listed as “anonymous” in all donor recognition materials.
PAYROLL DEDUCTION
I pledge a gift of $
I pledge a gift of
to Kentucky State University. Total will be divided by _____ pay periods (max 26).
Pay Period
I authorize these deductions to be made from my paycheck until I change these arrangements in writing (please allow 30 days) or I am no longer employed by Kentucky State University.
26 Pay Period Example
| Gift Per Pay Period | Total Gift for Year |
|---|---|
| $72.54 | $1,886 |
| $38.46 | $1,000 |
| $19.23 | $500 |
| $9.62 | $250 |
| $3.85 | $100 |
| $1.92 | $50 |
ONE-TIME DONATION
Amount: $_____
Amount
Payment options:
☐ Cash
q Cash
Check (payable to Kentucky State University)
q Check (payable to Kentucky State University)
Payroll Deduction
q Payroll Deduction
Credit Card: Visa
q Master Card
Master Card
q Discover
□ Discover
q American Express
American Express
q American Express
Card #:_____
Card
Exp. Date: ___
Exp. Date
Security Code: ___
Security Code
<div style="text-align: center;"><img src="imgs/img_in_image_box_0_1_1123_85.jpg" alt="Image" width="99%" /></div>
Designate my contribution to:
Where the need is the greatest
□ Where the need is the greatest
q Unrestricted Scholarship Fund
Unrestricted Scholarship Fund
q Other ________________________________________________________
Other ___
q Other
q Other ________________________________________________________
SIGNATURE: ___ DATE: ___
SIGNATURE
DATE
Please return this completed form to the Office of Institutional Advancement
Kentucky State University | 400 East Main Street Hume Hall Suite 202 | Frankfort, KY 40601
advancement@kysu.edu | 502-597-5500