Employee Campaign Payroll Deduction Form

Samaritan Employee Giving Campaign

Deduct my Gift from my Payroll

Name(Required)

Prefix First Last

Department(Required)

Employee ID

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Preferred name for publication. Write N/A if you wish to remain anonymous.(Required)

Amount Per Paycheck:(Required)

Set number of pay periods this amount will be deducted: (To continue until you cancel, type "Until I cancel")(Required)

My total gift amount = amount per paycheck x number of pay periods: (for ongoing deductions, type "ongoing")(Required)

Best Use – Samaritan Foundation

Please type the amount per paycheck you wish to donate to the Samaritan Foundation

Behavioral Health Services

Please type the amount per paycheck you wish to donate to Behavioral Health Services

Cardiac Catheterization Lab

Please type the amount per paycheck you wish to donate to the Cardiac Catheterization Lab

Children's Miracle Network of NNY

Please type the amount per paycheck you wish to donate to the Children’s Miracle Network of NNY

Circle of Hope

Please type the amount per paycheck you wish to donate to Circle of Hope

Long Term Care

Please type the amount per paycheck you wish to donate to Long Term Care

Your gift qualifies you for incentives like drawings, lanyards or T-shirts.(Required)

Include me in incentives

I prefer to not receive incentives

For gifts $25+ please enter your unisex shirt size:

If you would like to make this gift in honor or memory of someone, or if you have comments to share about your gift, please provide details here.

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