St. Mary's Philanthropy@Work

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**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 payment options below.
General Deduction
Please deduct the following amount (for 26 pay periods or one-time, as noted below), starting January 3, 2020.

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PTO Deduction
Please deduct the equivalent of one hour or more of my pay (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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Hourly Wage Deduction
Please deduct the equivalent of one hour or more of my pay (for 26 pay periods or one time, as noted below), starting January 3, 2020. *Note* Hourly wage donations can be made in half hour increments.

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I would like my gift to support:
Please select the area/program you would like your gift to support.
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*Technology, Equipment, Building

Digital Signature
Entering my full name below indicates I authorize CHI Health to process 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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