Request for Payroll Deduction for Perkiomen Valley Education Foundation

Please complete this form to elect an automatic payroll contribution for the PVSD Education Foundation.

You may also download a PDF of the form here.

Employee Name*
First Last
Building #*
Employee ID # or Last Four Digits of Social Security #*
Amount of payroll contribution:
- $1 Per Pay
- $2 Per Pay
- $5 Per Pay
Other Amount Per Pay
Effective Date of Contribution:*
Date Format: MM slash DD slash YYYY
I give my permission for the Foundation to list my name as part of the Annual Appeal*
- Yes
- No
I authorize the amount elected above to be deducted from my paycheck each pay period. This deduction will continue until the Payroll Department receives written notification. Authorized E-Signature:*