===== PAGE 1 ===== ## PAYROLL OFFICE USE ONLY # Employee Donation Form KENTUCKY STATE UNIVERSITY Amount per pay period ____Number of pay periods ____Date of first deduction ____Received on ____Received by _____ ## Yes! Iwill participate in the Employee Campaign and it will send astrong message that Ibelieve in Kentucky State University'smission! Employment Category: Faculty Adjunct Faculty Full-Time Staff Part-Time Staff Name__KSU ID #__Address __City __State __Zip __Email ____Phone ____Department ____Campus Phone ____Check if you would like to be listed as "anonymous" in all donor recognition materials. ## PAYROLL DEDUCTION Ipledge agift of to Kentucky State University. Total will be divided by _____ pay periods (max 26). 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: $_____ Check (payable to Kentucky State University) Payment options: Payroll Deduction ☐ Cash Credit Card: Visa Master Card □ Discover American Express Card #:_____ Exp. Date: ___ Security Code: ___ Designate my contribution to: Where the need is the greatest Unrestricted Scholarship Fund Other ___ 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