Name: / EMPLOYEE #:
**Your employee # can be found on the top right corner of your pay stub
Region#: Division#: Home Office
Department#: NAT’L Store#: WORK TELEPHONE #:
This form can be used to begin, change, or stop deductions to RMHC & America’s Charities.
This form can be used to change or stop deductions to the Credit Union.
To begin deductions for the Credit Union, you must contact Corporate America Credit to establish an account at 800-359-1939.
Section I:
Corporate America Credit Union Payroll Deduction Authorization (CRUN) / Please change my current Credit Union payroll deduction to $ per pay period.
I understand that these funds will be sent to my account at the Corporate America Credit Union.
Change Effective Date: ___
Please stop my Credit Union payroll deduction.
Section II:
RMHC Payroll Deduction Authorization (RMHC) / STAFF EMPLOYEES:
Please stop my RMHC payroll deduction. Change Effective Date: ___
To contribute to RMHC (Ronald McDonald House Charities), refer to the America’s charities section iv below.
store employees:
Please begin or change my rmhc payroll deduction to $ ______per pay period.
Please stop my RMHC payroll deduction. Change Effective Date: ___
Section III:
America’s Charities Payroll Deduction Authorization / PLEASE CHECK ONE: sign-up change pledge cancel pledge One-time gift
Enter YOUR FAVORITE CHARITies information BELOW. YOU MAY MAKE MULTIPLE SELECTIONS.
payroll deduction option:
Tax ID # -
agency name: ______payroll deduction $ per pay period
Tax id # -
agency name: ______payroll deduction $ per pay period
tax id # -
agency name: ______payroll deduction $ per pay period
tax id # -
agency name: ______payroll deduction $ per pay period
tax id # -
agency name: ______payroll deduction $ per pay period
one-time gift option:
tax id # -
agency name: ______amount $ one-time Payroll deduction
TOTAL PAYROLL DEDUCTION PER PAY PERIOD: $ TOTAL PAYROLL DEDUCTION GIFT: $
aUTHORIZATION: I AUTHORIZE DEDUCTION OF THE AMOUNT SHOWN FROM EACH PAY PERIOD ($1 MIMIMUM PER PAY PERIOD) TO THE CHARITIES OR FEDERATIONS, AS INDICATED. I UNDERSTAND THAT I CAN CANCEL AT ANY TIME.
I WISH TO BE ACKNOWLEDGED FOR MY GIFT. (YOU MUST INCLUDE YOUR HOME ADDRESS, IN ORDER TO RECEIVE AN ACKNOWLEDGEMENT.)
HOME ADDRESS: ______CITY/STATE/ZIP: ______
NOTE: It may take 1 to 2 pay periods before your elections are effective.
Signature / Employee Signature: / Date:Please forward this completed form and all required attachments (if applicable) to: FORM 3811 10/21/16 McDonald’s Service Center Dept. 238, McDonald’s Corporation, 2111 McDonald’s Drive, Oak Brook, IL, 60523
Telephone #: (877) 623-1955 Fax #: (630) 623-5027 E-mail address: