RPCC Foundation Payroll Deduction Authorization Form

Payroll Deduction Form
Please complete the Payroll Deduction Authorization Form.
Name*
Employee ID*
Department
Email*
example@example.com
Phone
Payroll Deduction Details
I authorize River Parishes Community College (RPCC) to deduct the following amount from my payroll check each pay period as a charitable contribution to the RPCC Foundation:*

$5.00$10.00$20.00$30.00$40.00$50.00Other
Ongoing Payroll Deductions

I would like to make ongoing deductions. I understand I must submit a written 30-day notice to Human Resource to discontinue the payroll deductions.
The ongoing payroll deductions will begin on the following date.

MonthDayYear
Date
One-Time Payroll Deduction

I would like to make a one-time payroll deduction.
The single payroll deduction will be drafted on the following date.

MonthDayYear
Date
Designation of Funds
Please direct my gift to the following fund(s).*

Areas of Greatest NeedRPCC Foundation ScholarshipsRPCC Student Success or Emergency Relief FundProgram Development and Workforce TrainingTechnology ImprovementsCommunity Outreach InitiativesCapital Expansion and EnhancementsOther
Authorization and Signature
I understand that this deduction is voluntary and will continue as indicated above until I notify the RPCC Human Resources Office in writing to adjust or discontinue my contribution. I also understand that my payroll deduction contributions may be tax-deductible, and I will receive an annual summary for my records.
Date*

MonthDayYear
Date
Signature*

Clear
River Parishes Community College Foundation is a 501(c)(3) nonprofit organization. Your donation is tax-deductible to the extent allowed by law.
Should be Empty:

Payroll Deduction Form

Payroll Deduction Details

Designation of Funds

Authorization and Signature