equal opportunity/counseling
Charity Enrollment Form
TO: PAYROLL DEPARTMENT, MS-110
FROM: _________________________________________
(PRINT NAME)
EMPLOYEE # ___________
________ or _________
Weekly* Monthly*
I hereby authorize a payroll deduction for contributions to the following charities
(please provide the mailing address if you know it):
1.________________________________________________________
$ ___________ per pay period
Address_______________________________________________ State:__________ Zip Code:_________
2._________________________________________________________
$ ___________ per pay period
Address_______________________________________________ State:__________ Zip Code:_________
3._________________________________________________________
$ ___________ per pay period
Address_______________________________________________ State:__________ Zip Code:_________
Signed:______________________________________________________ Date: _____/_____/______
*Requires a minimum pledge of $52.00 annually for one charity and $78.00 for two or more.
Return this form to the Payroll Department, Mail Station 110, by December 5, 2005.
I authorize these deductions(s) to start with my next pay period and continue until I advise when they should stop.
Please make a copy of the completed form for your records.
