UC Impact Payroll Deduction

Payroll Deduction
Enter Donation Amount Here *
Select an Area to Support *
Enter Designation Here *
Please make my gift In Tribute Of/In Memory Of
Add Another Donation? *

Yes No
Enter Donation Amount Here
Select an Area to Support
Enter Designation Here
Please make my gift In Tribute Of/In Memory Of
Add Another Donation?

Yes No
Enter Donation Amount Here
Select an Area to Support
Enter Designation Here
Please make my gift In Tribute Of/In Memory Of
Donor Information
Employee ID# *
Primary Employer *
Title *
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address Type *

Home Business
Phone Number *

Area Code Phone Number
Phone Type *

Home Business Mobile
Permission to Publish

You may publish my/our name(s) in the UC Honor Roll of Donors and other gift publicity. I/we wish to remain anonymous.
Payroll Deduction Information
Deducted Amount per Pay Period *
Ex. $50
Number of Pay Periods *
Total Gift Amount
Pay Period in which to start deductions *
Pay-Period *

Bi-Weekly Monthly
I have an existing payroll deduction pledge. Please start this pledge after the last billing month.
Signature *
By typing your name in the Signature block, you are authorizing your pledge.
Should be Empty:

Payroll Deduction