Employee Payroll Deduction Form

Employee Giving – Payroll Deduction Authorization Form - FY 2016

Employee #: / Office Phone:
Name: / Work Email:
Position/ Department: / Home Phone:
Home Email:
Address:

Please complete and update the above information.

□ $50 / □ $100 / □ $250
□ $500 / □ $750 / □ $1,000 / □ Other ______

I would like to make a gift of:

I would like my gift to go to:

□ Unrestricted / □ The Cancer Program / □ Emergency Department / □ Nursing Excellence & Education / □ The Orthopaedic Program
□ Penn Heart & Vascular / □ Radiology Outpatient Services / □ Women’s Health Services:
□ Maternity □ NICU □ Pediatrics

Customize your deduction: (The earliest deductions can start is January 8th.)

□ I authorize Penn Medicine Chester County Hospital Payroll to deduct $______each pay for ______pay periods, starting with the first available pay in Month/Year______and ending Month/Year______for a total gift of $______. (There are 13 pay periods remaining in this fiscal year.)

Or choose from an option below: (The earliest deductions can start is Jan 8th.)

□ $2,000 per year ($153.85 per pay period for 13 pay periods)

□ $1,000 per year ($ 76.92 per pay period for 13 pay periods)

□ $ 750 per year ($ 57.69 per pay period for 13 pay periods)

□ $ 500 per year ($ 38.46 per pay period for 13 pay periods)

□ $ 250 per year ($ 19.23 per pay period for 13 pay periods)

□ $ 100 per year ($ 7.69 per pay period for 13 pay periods)

□ $ 50 per year ($ 3.85 per pay period for 13 pay periods)

Please note: The maximum # of years to pledge at one time is 5 years (maximum # of pays is 130). Once your pledge is fulfilled we will contact you for renewal. (There are 13 pay periods remaining in this fiscal year. Note that the dollars per pay will be less on the last pay period.)

The Foundation’s fiscal year runs from July 1 through June 30.

Your gift will be recognized based on the contributions made in the fiscal year.

□ I would like my gift to be listed as Anonymous.(I will not be listed by name and dollar amount in Foundation materials.)

Signature______Date______

Please return this form in the envelope provided or send in interoffice mail to:

The Chester County Hospital Foundation/ Development

Attn.: Tom Gavin

Questions, please contact Tom Gavin at or 610.431.5329