I agree to support the UCSD STUDENT FOUNDATION by paying the $5 per quarter STUDENT FOUNDATION PLEDGE FEE each quarter that I am a student at UCSD. Please bill me for this fee every quarter with my student account bill. I understand that this gift is a 100% tax-deductible charitable donation. I understand that if I no longer wish to be billed the STUDENT FOUNDATION fee, I must request discontinuation in writing to the UCSD Student Foundation, c/o UC San Diego Foundation, 9500 Gilman Drive, La Jolla, CA 92093-0940
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The State of California Information Privacy Act of 1977 (effective July 1, 1978) requires the University to provide the following information to individuals who are asked to supply information about themselves:

1) The principal purpose for requesting the information on this form is to process the voluntary fee (charitable gift) properly in the student billing and donor records as required by University policy.

2) Furnishing the information on this form is mandatory to ensure the gift can be billed and properly credited. Failure to provide such information will result in delay or inability to complete the action for which the form is being completed. Information furnished on the form may be used by the UCSD offices of Student Billing and External Relations and will be transmitted to the State and Federal governments and their agencies, if required by law.

3) Individuals have the right to review their student and donor records. The officials responsible for maintaining the information contained on this form are: Mark Cooper, Director, Student Business Affairs; 9500 Gilman Drive; La Jolla, CA 92093-0050; 858-822-2338 and UCSD Student Foundation, External Relations, Gift Administration; 9500 Gilman Drive; La Jolla, CA 92093-0940; 858-534-5289.