Employee Payroll Deduction Form

By submitting this information, you are giving Gundersen Medical Foundation permission to contact the Payroll department to start the specified payroll deduction amount. Your gift is an ongoing recurring gift unless you elect to change it. We will contact you on an annual basis to update your preferences. Thank you for your generosity.

Your name

Recognition name

Please print your name as you wish it to appear on Foundation recognition lists and publications (you may include your spouse/significant other)

Employee number

Gift per pay period

Pay periods

Date to start deduction

Please designate how you want your gift to be directed

Designate recipients	Percentage split of gift (if multiple selected)
Recipient entity Recipient entity Enter other…	Percentage
Recipient entity Recipient entity Enter other…	Percentage
Recipient entity Recipient entity Enter other…	Percentage

Select this if you would like an acknowledgement of your gift sent out.

Gift acknowledgment

Memorial and honorarium information

Recipient name

Address

Address 2

City/town

State/province

ZIP/postal code

Country

Special note about this gift

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