Payroll Authorization

Payroll Authorization

PDF Version
Section ONE: Employee Information

Complete to authorize a new payroll deduction(s), to increase existing deduction(s) or to cancel old deduction(s). All may be done on a single form. All donations are tax deductible.


Minimum of $2.50 donation per Charity per pay period

Authorize Pay To & Amount

Charitable Agency #1


Charitable Agency #2


Charitable Agency #3


Charitable Agency #4


Charitable Agency #5


Charitable Agency #6


Charitable Agency #7


Charitable Agency #8


Charitable Agency #9


Charitable Agency #10


Charitable Agency #11

Section TWO: Donor Designation

You may designate your payroll deductions to go to any 501(c)(3) nonprofit charitable organization by selecting one of the above starred* Fund Distribution Agencies to process your donation. We will need the name and address of the charity and the name of the FDA to be indicated below. All designations remain in place unless cancelled by donor in writing. Please note all the FDA’s are required to forward donor designations quarterly.

Section THREE: One-Time Gifts

You may make a one-time gift to any of the above listed charitable agencies by filling out the information below and indicating your choice of charity. You may also make a one-time gift to any 501(c)(3) nonprofit charitable organizations by selecting one of the above starred* Fund Distribution Agencies to process your donation. A Charity Representative will reach out with further details on how to make this One-Time Gift.

Section FOUR: Acknowledgement

To receive an acknowledgement of your donation, Please fill in the questions posted below. Your personal information will not be sold or given to any other agency.

Certification: I, the undersign, certify that all statements contained herein, are true and correct to the best of my knowledge. I understand the information I provide in this certification is subject to verification and agree to provide necessary documentation if requested to do so.