Employee Payroll Deduction Form

Please complete the following information requested for payroll deduction.

I am paid on a basis of	bi-weekly 10 month 12 month
Deduct per paycheck:
Please allocate my gifts as follows:
	Lipscomb Fund: (unrestricted)
Amount per year $:
	Other Fund: (Lipscomb Academy; National Bison Club;institute, college, departmental funds, scholarships, etc.)
Amount per year $:
To fund:
Amount per year $:
To fund:
Amount per year $:
To fund:
Amount per year $:
To fund:
Amount per year $:
To fund:
By filling out the information below, you are authorizing the university to deduct the information given above.
Full Name:
Today's Date:
L #:
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