“Choose to Care”

Payroll Deduction Form                               2007– 2008 CAMPAIGN

TO:      Payroll Department

 _____________________________________

FROM:            Employee Name ____________________________________

                        Employee ID ____________________ (if applicable)

ABSOLUTELY! You can count on me! I Choose to Care!

Here’s my pledge to help our youth, our elderly and our neighbors in need in Wise County.

TOTAL ANNUAL PLEDGE: ___________________________

Option 1 - Payroll Deduction, Percentage per pay period:

          Please deduct the following checked item from my regular paycheck:

                        __ 1% of salary  __2% of salary  __1 hour’s pay/mo  __2 hour’s pay/mo

          Beginning with the pay period __________________

          And continuing for ____ pay periods

Option 2 – Payroll Deduction, $$ per pay period:

          Please deduct $_________ from my regular paycheck

          Beginning with the pay period __________________

          And continuing for ______ pay periods

Option 2 – One-time Payment:

                    Please forward attached check for $___________ to United Way of Wise County.

                    (Check should be made out to “United Way of Wise County”.)

 

Signature: ________________________________________

Thank you! Your contribution is very important to the people of Wise County. Please return completed form as soon as you can to your Payroll Department.