Employee Giving Campaign

I wish to participate in the 2021 Employee Giving Campaign as indicated below. All gifts are tax deductible in accordance with IRS regulations.

Designate my gift to one of the following:*

Fairview Hospital Employee Care Fund Lutheran Hospital Employee Care Fund Avon Hospital Employee Care Fund

Name*

First Name

Last Name

Department*

Extension

Home Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Your Phone*

Email

Is this an Honorarium or Memorial gift?*

Yes No

The above gift is made:*

In Honor of... in Memory of...

Honoree/Memorium Name

First Name

Last Name

You will receive a letter of acknowledgement for this Honorarium/Memorial donation. Is there another person or organization you would like notified on your behalf? If so, after selecting "Yes", please include their name and address directly below:

Yes No

Acknowledgement Information

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Method of Donation*

Credit Card Payroll Deduction PTO Donation

Charge the Following Amount to My Credit Card* $

Credit Card*

Name on Card*

First Name

Last Name

Cardholder Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Cardholder Phone*

Choose recurring payroll deduction or one-time payroll deduction*

Payroll deductions will begin as soon as the payroll department processes your donation request. Make a one-time only deduction in the following amount

All gifts provided through payroll deduction can be found as the year-to-date amount on your last printable pay stub.

Deduct the following amount each pay* $

All gifts provided through payroll deduction can be found as the year-to-date amount on your last printable pay stub.

Make a one-time only deduction in the following amount* $

All gifts provided through payroll deduction can be found as the year-to-date amount on your last printable pay stub.

Employee Number*

Deduct the following hours of my PTO (minimum eight hours)*

Gross deduction amount is taxable income and subject to regular deductions.

Employee Number*