Emporia State University
ESU Regents Payroll Deduction Agreement
ESU Foundation
Social Security # Last Name First Name MI
Division Campus Box Extension
To participate in the payroll deduction program, you must be a permanent classified or unclassified employee in a 50%-time or more position.
Please check only 00ne00 of the following:
_________ 9-month Employee _________ 12-month Employee
Begin the deduction with the next available pay period.
Amount Per Pay Period $_________ Total Deduction Per Calendar Year $____________
Designation(s): ______________________________________________________________
______________________________________________________________
______________________________________________________________
Please check only 00ne00of the following:
____ I intend for this deduction to continue each year until I notify the Foundation in writing
of any changes.
____ I wish to be contacted each year to re-authorize my payroll deduction.
This is a voluntary decision on my part and I accept the risks associated therewith. I understand that if at any time I do not have net pay sufficient to cover the deduction, the Payroll Office will remove the deduction and notify me as well as the Foundation Office as soon as possible. This authorization is in effect until I provide written notification to the Payroll Office to cancel the deduction.
Date ___________ Signature ________________________________________________
Employee
Date ___________ Signature ________________________________________________
ESU Foundation
Return form to the ESU Foundation, Campus Box 4002Copies: ESU Foundation Box 4002
Payroll Office Box 4028
(over)
The charts below represent how much can be contributed by utilizing payroll deduction. There are 26 pay periods during the calendar year. Employees can designate how much they want withheld from each pay check and for how many pay periods they want it withheld.
For instance, having $5 withheld for all 26 pay periods would result in a total annual gift of $130.
# of Pay Periods
1 2 3 4 5 6 7 8 9 10 11 12 13 $5 5 10 15 20 25 30 35 40 45 50 55 60 65 AmountWithheld Per Pay Period$10
10 20 30 40 50 60 70 80 90 100 110 120 130 $15 15 30 45 60 75 90 105 120 135 150 165 180 195 $20 20 40 60 80 100 120 140 160 180 200 220 240 260 $25 25 50 75 100 125 150 175 200 225 250 275 300 325 $30 30 60 90 120 150 180 210 240 270 300 330 360 390 $40 40 80 120 160 200 240 280 320 360 400 440 480 520 $50 50 100 150 200 250 300 350 400 450 500 550 600 650 $60 60 120 180 240 300 360 420 480 540 600 660 720 780# of Pay Periods
14 15 16 17 18 19 20 21 22 23 24 25 26 $5 70 75 80 85 90 95 100 105 110 115 120 125 130 AmountWithheld Per Pay Period$10
140 150 160 170 180 190 200 210 220 230 240 250 260 $15 210 225 240 255 270 285 300 315 330 345 360 375 390 $20 280 300 320 340 360 380 400 420 440 460 480 500 520 $25 350 375 400 425 450 475 500 525 550 575 600 625 650 $30 420 450 480 510 540 570 600 630 660 690 720 750 780 $40 560 600 640 680 720 760 800 840 880 920 960 1000 1040 $50 700 750 800 850 900 950 1000 1050 1100 1150 1200 1250 1300 $60 840 900 960 1020 1080 1140 1200 1260 1320 1380 1440 1500 1560Emporia State University Annual Giving Levels
Loyalty up to $99
Century $100 - $249
Hornet $250 - $499
KSTC $500 - $999
Ambassador $1,000 - $2,499
Chairman $2,500 - $9,999
Sustainer $10,000 - $24,999
Medallion $25,000 - $49,999
Patron $50,000 and above
* * * * *
Black & Gold Society $1,500 annual gift to new
presidential membership
organization
For more information, contact:
Teddi Davis
Pledge & Gift Coordinator
ESU Foundation
Campus Box 4002
620-341-6462
tdavis@emporia.edu
