Dickinson ISD Education Foundation Payroll Deduction Authorization Agreement

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**Deadline of October 2, 2023 to be eligible to receive incentives**

The Dickinson ISD Education Foundation is a legally incorporated, non-profit, charitable and education corporation. Our status as a 501(c)(3) foundation allows us to receive and distribute funds, property and gifts of any kind to benefit Dickinson ISD.

Your donation to Gator Nation Cornerstone Club will provide innovative teaching grants for all campuses and scholarships for Dickinson High School seniors.

I understand by completing this payroll deduction authorization agreement, I hereby authorize my employer Dickinson Independent School District to deduct the amount specified per pay period on behalf of the Dickinson ISD Education Foundation. This is a tax-deductible contribution and is recommended you keep record of your contribution for claiming a deduction on individual tax returns. The deduction amount will appear on the employee pay stub and W-2.

I understand upon completion of this payroll deduction authorization agreement I will receive email confirmation of my responses for my records. This authorization shall become effective upon receipt and shall remain in effect until a Cancellation/Change Request form has been submitted to the Dickinson ISD Business Office at least 30 days prior to the next scheduled payday.

First Name: *

Last Name: *

Employee ID: *

Employee E-mail Address: *

Employee Work Phone Number: *

Campus/Department: *

Participation Incentives By Giving Level:

I herby authorize the following payroll deduction amount to join Gator Nation Cornerstone Club: *

Minimum contribution for participation = $5 per paycheck

$5 per pay period through payroll deduction

$8 per pay period through payroll deduction

$10 per pay period through payroll deduction

$15 per pay period through payroll deduction

Other (See next question.)

Required

If you selected "Other" above, please indicate your desired donation amount.

(Note: Donation amounts will be per pay period and must be above $15.)

DEF Website and/or Publications *

Yes, I consent to my name being listed as a donor on DEF website and/or publications

No, I do not consent to my name being listed as a donor on DEF website and/or publications

Required

Thank you,

Your donation made to the above-mentioned 501(c)(3) Non-Profit Organization will help to continue the education, growth and future opportunities of Dickinson ISD students. As leaders for tomorrow our students need and appreciate the support provided through your donation and the foundation is proud to have you as one of our supporters.

We, the undersigned representative, declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that there were no goods or services provided as part of this donation. Furthermore, as of the date of this receipt the above-mentioned organization is a current and valid 501(c)(3) non-profit organization in accordance with the standards and regulations of the Internal Revenue Service (IRS).

Amy C. Garza
Dickinson ISD Education Foundation Inc.

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