Brasfield & Gorrie Impact Week 2023 – Payroll Deduction Contact InformationName(Required) First Last Job Title(Required) Dept/Location(Required)Employee IDHome Address Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Giving OptionsRecurring Payroll DeductionI want the following amount deducted per pay period: $5 $10 $15 $25 Other One-Time Payroll Deduction $25 $50 $75 $100 Other SignatureFull Name(Required) I authorize my employer to deduct the amount selected from my paycheck either each pay period or one time (as indicated) as a charitable contribution from me to Friends of Children’s Hospital. I understand that I may cancel my donations at any time by providing written notice to my Payroll Department at least 30 days prior to the effective scheduled pay date. No goods or services were provided in exchange for this contribution. Date(Required) MM slash DD slash YYYY
