Employee Giving - Payroll Deduction Form

For questions, contact Molly Moshofsky Matheson, Associate Director of Development. Email: mollym@lclark.edu Phone: x6934

First Name*

Preferred First Name

Last Name*

LC ID*

LC Email Address*

Campus Department*

MSC*

Campus Phone*

Payroll Deduction

Is this a new deduction or update to a current deduction?*

New deduction

Update to current deduction

Lewis & Clark Fund Designation

Amount per Paycheck

Start Date
Deductions are ongoing unless updated or canceled by employee

Required Authorization

Electronic Signature*
Type full name

Verify and Authorize*

By checking this box and signing my name above, I authorize Lewis & Clark College to withhold the amounts indicated above from each paycheck. I understand that deductions made to Lewis & Clark are ongoing without end unless changed by me.