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)

I authorize Samaritan to make the following deductions from my pay:(Required)

Amount Per Paycheck

Number of Pay Periods I wish to donate the amount listed above:(Required)

My total gift amount:(Required)

Where would you like to direct your donation?(Required)

Samaritan Foundation

Behavioral Health Services

Cardiac Catheterization Lab

Children’s Miracle Network of NNY

Circle of Hope

Long Term Care

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

Include me in incentives

I prefer to not receive incentives

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