PAYROLL DEDUCTION AUTHORIZATION

Please print this page, complete the required information, and forward it to the Office of University Human Resource Services.

Printed Name:
____________________________  __________________________________   
Last                                                            First                        

|__|__|__| |__|__| |__|__|__|__|
BSU Identification Number

Signature:        _______________________                     Date: ________________

I authorize Ball State University to make the following deduction from my payroll
check for remittance to the United Way of Delaware County.

Deduct $ __________   per month, until a total pledge of $ _____________  has been met.

I am paid:   [__]  Bi-Weekly     [__]  Monthly.

Annual campaign deductions will start with the first check received in November.   

____   Check here to stop an authorization after it has been submitted for the campaign year.

Deduction Code: 320.      Form PEB 20. 5/2003.  Rev 6/2006