You can select the program you want to support at St. Elizabeth, Nebraska Heart or The Physician Network. Just imagine what we can do together if each of us gives! We want you to know that every dollar counts, and your gift is appreciated.

Employee Payroll Deductions

CHI Health St. Elizabeth, CHI Health Nebraska Heart, The Physician Network, and affiliates

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Gift Information
**Please Note** Deductions must be a minimum of $1 per pay period. If you select more than one fund, you must contribute a minimum of $5 per fund, per pay period. Your total donation will be divided equally between all funds selected.
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Please choose your gift options below.
Be a member of the Hour Club
Please deduct the equivalent of one hour or more of my pay (for 26 pay periods or one time only, as noted below), starting January 3, 2020. *Note* PTO donations can be made in half hour increments.

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By Payroll Deduction
Please deduct the following amount (for 26 pay periods or one time only, as noted below), starting January 3, 2020.

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By PTO Deduction
Please deduct the number of hours of PTO listed below, (for 26 pay periods or one time only, as noted below), starting January 3, 2020. *Note* PTO donations can be made in half hour increments.
**NOTE** The gross value of donated PTO hours will be forwarded to the foundation. The employee will pay taxes on the gift.

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I would like my gift to support:
Please select the fund(s) you would like your gift to support.
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Digital Signature
Entering my full name below indicates I authorize CHI Health to withhold my payroll deduction as indicated above. I understand that the information on this form will be entered into the Foundation database and used to administer this donation, send acknowledgements and tax statements, etc.
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