Better Together Payroll Deduction Form |

Employee Information

Please fill out all sections. Please provide a mailing address so that we can send you a tax acknowledgement letter for your records.

Name*

First M.I. Last

Campus*

Home Address*

Street Address Address Line 2 City State ZIP Code

Email

Phone

Giving to Support Sun Health's Nonprofit Mission

Payroll deductions for this campaign will begin with the second paycheck received in January.

Payroll Deduction

$ 25 per pay period
$ 15 per pay period
$ 10 per pay period
$ 5 per pay period
Custom Amount
One time payroll deduction

Amount to contribute per pay period

One-time payroll deduction of:

Please enter a number greater than or equal to 10.

(minimum $10)

YES! Please automatically renew my pledge every year. You can cancel or update this at any time by contacting your HR representative.

Allocate 100% of your contribution to a single fund OR, using percentages, divide it among no more than 2 funds.
If no designation is indicated, your donation will be allocated to the General Fund for use in the areas of greatest need.

Funds

Operation Thanksgiving
Team Member Emergency Fund (03AF)
Other (please specify)

% to Operation Thanksgiving

Please enter a number from 0 to 100.

% to Team Member Emergency Fund (03AF)

Please enter a number from 0 to 100.

% to Other

Please enter a number from 0 to 100.

to

tell us how you'd like these funds used.

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Total %

Signature

For purposes of donor recognition, I prefer my gift to remain anonymous.