St. Francis 2020 P@W Campaign

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**Please note** Deductions must be a minimum of $1 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 (for 26 pay periods or one-time, as noted below), starting January 3, 2020.

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By PTO Deduction
Please deduct one hour or more of PTO (for 26 pay periods or one time, 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. Employee will pay taxes on the gift.

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I would like my gift to support:
Please select the area/program you would like your gift to support. Undecided? Your gift could help various programs and services such as Child Safety, Cancer Treatment Center, Maternal Child, Chapel, and many more. Select Other and write in where you would like your donation to be directed.
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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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