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1250 BELLFLOWER BOULEVARD
LONG BEACH, CALIFORNIA 90840
562.985.4111

Employee Payroll Deduction

Students on CSULB Campus

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Employee Payroll Deduction

Employee Payroll Deduction

ourBEACH

Payroll Deduction Form for Voluntary Contributions. Please use this form to initiate, change, or cancel your payroll deduction.

Thank you in advance for your support of The Beach!

Last Name

First Name

M.I.

I am a

CA State Employee

CSULB Research Foundation Employee

College/Dept/Program

Campus Address

Campus Email

Home Address

City

State

Check all that apply

Faculty

Staff

Emeriti Faculty/Staff

Retired Faculty/Staff

CSULB Alumni

Year

Major

Name when enrolled

Payroll Deduction

Type

New Deduction

Change Deduction (replaces existing deduction)

Cancel Deduction

Please allocate my gift to (min. monthly allocation is $10 per fund)

Fund Description

Amount

Fund Description

Amount

Fund Description

Amount

Printed name of signer

Date

For Office Use Only

Consent

I hereby authorize the State Controller or the CSULB Research Foundation to deduct from my salaries and wages the amount specified now or in the future for philanthropic gifts for which I have agreed, which are maintained by the CSULB 49er Foundation. This authorization will remain in effect until cancelled by CSULB, the CSULB Research Foundation or me. Payroll deduction contributions may be tax-deductible. Please consult your tax advisor. Annual gift acknowledgements will be provided for tax purposes.

Note

If you need additional information, please contact Julie Wilson at (562) 985-8867

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1250 BELLFLOWER BOULEVARD
LONG BEACH, CALIFORNIA 90840
562.985.4111