Payroll Deduction Contribution Form for Employees

First Name:*

Last Name:*

APSU Email:*

Department:*

APSU Phone Number:

Home or Cell Phone Number:*

My pay period is:*

I wish to contribute the following each pay period:

If you selected other as the amount, please indicate here how much you wish to contribute each pay period.

If you do not wish to have a recurring payroll deduction, you can choose a one-time deduction. Please indicate that amount below.

My one-time deduction amount is:Please enter the total of your one-time deduction. One-time payroll deductions will be taken out the first pay period in January.

TOTAL ANNUAL GIFT:($ per pay period x # of pay periods - or - one time deduction amount)

Designating My Gift*