2024 Employee Giving - Payroll Deduction Form

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* 1. Today's Date

Date

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* 2. Employee Information

Name

Employee ID#

Street Address

City

State

Zip

Phone

Department

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* 3. I OFFER MY SUPPORT
"By checking one of these boxes your participation will be counted in this year’s campaign and an entry into the raffle"

I would like to donate to PMPH

While I am unable to contribute financially to the Foundation at this time, I have supported other organizations outside of Princeton Medical Center this year, and I look forward to potentially contributing to the PMC Foundation in the future.

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* 4. I OFFER MY SUPPORT IN THE AMOUNT OF:
*Your payroll deduction will be ongoing until the Foundation is notified.

$1.93 per pay period ($50 per year)

$3.85 per pay period ($100 per year)

$9.62 per pay period ($250 per year)

$19.25 per pay period ($500 per year)

$38.48 per pay period ($1,000 per year)

One Time Gift Amount (through payroll deduction)

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* 5. Please check here if you are an existing Employee Donor and this is an increase or additional deduction.

New Payroll Deduction

Update My Current Payroll Deduction

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* 6. I WOULD LIKE MY DONATION TO BENEFIT:
*Please choose ONE fund for your payroll deduction.

Employee Benevolent Fund

Project Thrive

Other: (please specify dept.)

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* 7. Donors who make a new or increased financial contribution, either through payroll deduction or a one-time cash/check donation, will be entered twice into the raffle.

I have read the above statement

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* 8. Print name(s) as you wish to be recognized:
(if you would like to give anonymously (without public recognition), please write ANONYMOUS)

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* 9. I hereby authorize my employer, Penn Medicine Princeton Health, to deduct from each paycheck the amount listed above for my charitable contributions to Princeton Medical Center Foundation. I understand that I may withdraw from this plan or alter it at any time by making a written request to the Princeton Medical Center Foundation. I understand that my payroll deductions for Princeton Medical Center Foundation are tax-deductible to the extent provided by law. I will receive an acknowledgement for tax purposes on a yearly basis from the Foundation.

I have read the above payroll deduction statement

2024 Employee Giving - Payroll Deduction Form

Question Title

* 1. Today's Date

Question Title

* 2. Employee Information

Question Title

* 3. I OFFER MY SUPPORT "By checking one of these boxes your participation will be counted in this year’s campaign and an entry into the raffle"

Question Title

* 4. I OFFER MY SUPPORT IN THE AMOUNT OF: *Your payroll deduction will be ongoing until the Foundation is notified.

Question Title

* 5. Please check here if you are an existing Employee Donor and this is an increase or additional deduction.

Question Title

* 6. I WOULD LIKE MY DONATION TO BENEFIT: *Please choose ONE fund for your payroll deduction.

Question Title

* 7. Donors who make a new or increased financial contribution, either through payroll deduction or a one-time cash/check donation, will be entered twice into the raffle.

Question Title

* 8. Print name(s) as you wish to be recognized: (if you would like to give anonymously (without public recognition), please write ANONYMOUS)

Question Title

* 3. I OFFER MY SUPPORT
"By checking one of these boxes your participation will be counted in this year’s campaign and an entry into the raffle"

* 4. I OFFER MY SUPPORT IN THE AMOUNT OF:
*Your payroll deduction will be ongoing until the Foundation is notified.

* 6. I WOULD LIKE MY DONATION TO BENEFIT:
*Please choose ONE fund for your payroll deduction.

* 8. Print name(s) as you wish to be recognized:
(if you would like to give anonymously (without public recognition), please write ANONYMOUS)