H.O.P.E. 2020 United Way Employee Donations

CHI Health Good Samaritan Foundation

My personal information
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Gift Information
**Please note** Deductions must be a minimum of $5 per pay period. If you select more than one fund, you must contribute at least $5 per fund, per deduction. Your total donation will be divided equally between all funds selected.
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Please choose your gift options below.
By Payroll Deduction
Please deduct the following amount (per pay period for 26 deductions, or one-time, as noted below), starting January 3, 2020.

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By PTO Deduction
Please deduct the number of hours of PTO listed below, (.5 hours or more, for 26 pay periods or one time only, as noted below), starting January 3, 2020.
**NOTE** The gross value of donated PTO hours will be forwarded to the foundation. Employee will pay taxes on the gift.

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I would like my gift to support:
Please select the United Way area/program you would like your gift to support.

Digital Signature
Entering my full name below indicates that I authorize CHI Health to withhold my payroll deduction as indicated above. I understand that the information on this form will be entered in the Foundation database and used to administer this donation, send acknowledgements and tax statements, etc.
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