$ per year for years.* (Eg. Standard 12-month appointment: $83.34 x 24 pay periods x 5 years=$10,000

Name (Faculty/Staff/Retiree)

UW employee ID (EID, for payroll deduction)

Address line 1

City State Zip

Telephone

Email

Pledge amount ($10,000+)

Your gift is tax deductible as specified in IRS regulations. Pursuant to RCW 19.09, the University of Washington is registered as a charitable organization with the Secretary of State, state of Washington. For information call the Office of the Secretary of State, 1-800-332-4483.

Spouse ID: Donor ID:

Staff Name: Allocation/Budget:

PLEDGE INFORMATION (NOT TO EXCEED 5 YEARS)

DRAFT

Date:

Date:

TO BE COMPLETED BY THE UNIVERSITY

Required for new endowments: - Gift meeting endowment minimum - Signed gift agreement

FACULTY STAFF RETIREE: CAMPAIGN FOR STUDENTS

PLEDGE FORM

Donor Signature:

Donor Signature:

Spouse/Partner name

Address line 2

University Advancement Donor Relations

4333 Brooklyn Ave NE, Box 359504 Seattle, WA 98195-9504

steward@uw.edu

Matching Funds Reserved:

for a period of years.PLEDGE: I (we) would like to make payments of $ beginning on (month/year).

Spouse/Partner email

I am establishing anew endowment

SIGNATURE(S)

Please send pledge reminders to the address above.

Endowment name

PAYMENT OPTIONS (PLEASE CHOOSE ONE)

per paycheck for a total of PAYROLL : I authorize the University of Washington to deduct $

* This option is only available for current faculty and staff. Your first payroll deduction will be on the first pay period of themonth following the receipt of this pledge form. If this FSR multi-year pledge is intended to modify a current payrollpledge or you have changes or questions regarding your current payroll deduction please contact payrgift@uw.edu.

I (we) would like to make a pledge payment of $ now.

Date Reserved :

Faculty with a 9-month appointment: $111.12 x 18 pay periods x 5 years = $10,000)

Advance Giving Code: FSR17