2003 pledge form - Northern Lights CFC

Northern Lights
Combined Federal Campaign #0481
Note: CFC payroll deductions start with the first pay period that begins in January 2016 and ends with
the last pay period that begins in December 2016.
CIVILIAN/POSTAL
not less than $1 per period
$5 x 26 pay periods
$10 x 26 pay periods
$15 x 26 pay periods
$20 x 26 pay periods
$25 x 26 pay periods
$30 x 26 pay periods
$40 x 26 pay periods
$50 x 26 pay periods
$60 x 26 pay periods
$90 x 26 pay periods
$100 x 26 pay periods
$116 x 26 pay periods
$193 x 26 pay periods
WRITE IN TOTAL
$130
$260
$390
$520
$650
$780
$1,040
$1,300
$1,560
$2,340
$2,600
$3,016
$5,018
MILITARY
not less than $2 per month
$5 x 12 months
$10 x 12 months
$15 x 12 months
$25 x 12 months
$50 x 12 months
$85 x 12 months
$130 x 12 months
$195 x 12 months
$250 x 12 months
$417 x 12 months
WRITE IN TOTAL
$60
$120
$180
$300
$600
$1,020
$1,560
$2,340
$3,000
$5,004
If you want to change the world, be that change.
Mohandas Gandhi
Thank you for supporting the Combined Federal Campaign!
NORTHERN LIGHTS COMBINED FEDERAL CAMPAIGN
1619 Dayton Ave, Suite 323, St. Paul, MN 55104
FIRST
MIDDLE INITIAL
WORK ADDRESS & ZIP CODE
CHECK (if applicable)
■ Civilian
■ Military
FEDERAL AGENCY AND OFFICE
AMOUNT
MILITARY PAYROLL
Branch of Service?________________
CIVILIAN PAYROLL
CASH/CHECK
Check Number:
INTERVAL
SOCIAL SECURITY NUMBER /EMPLOYEE ID
WORK PHONE NUMBER
(
CONTRIBUTION: Fill in the blank showing the amount of your payroll allotment, cash or check contribution.
Write in the total of your annual contribution in the space provided.
ALLOTMENT SOURCE
0481 27 6330
)
CHARITY CODE
ANNUAL AMOUNT
TOTAL GIFT
X 12 months
$
X 26 pay periods
$
Cash/Check Amount:
$
(make check payable to the Combined Federal Campaign)
CFC Organizations do not provide goods or services in whole or partial consideration for any
contributions made to the organizations via this pledge card.
INFORMATION RELEASE (OPTIONAL)
Any information you enter below will be released, along with your name, to the
charity(ies) to which you made a pledge. Do not enter your work address or email.
Home Address
_____________________________________________
_____________________________________________
Personal Email Address
_____________________________________________
■ In addition to my contact information, I authorize the CFC to release the amount
of my pledge to the charity(ies) I designated above.
www.northernlightscfc.org
DESIGNATED GIFT: To designate one or more charities or federated groups, fill in the
charity code(s) and dollar amounts above. Undesignated gifts are distributed among all
organizations in proportion to their pledges.
PAYROLL DEDUCTION AUTHORIZATION
I hereby authorize any agency of the United States Government by which I may be employed during 2016
to deduct the amount(s) shown above from my pay each pay period during the calendar year 2016 starting
with the first pay period that begins in January and ending with the last pay period that begins in December,
and to pay the amounts so deducted to the Combined Federal Campaign shown above. I understand that
this authorization may be revoked by me in writing at any time before it expires.
SIGNATURE _______________________________________________ DATE ___________________________
OPM FORM 1654 REV. MAY 2015
COPY #1 – PAYROLL OFFICE
PLEASE USE BALLPOINT PEN AND WRITE FIRMLY
PRINT NAME (LAST)
CFC Campaign No. City/State Code: ATTENTION PAYROLL OFFICES:
Only use this number to identify
the local campaign.
NORTHERN LIGHTS COMBINED FEDERAL CAMPAIGN
1619 Dayton Ave, Suite 323, St. Paul, MN 55104
FIRST
MIDDLE INITIAL
WORK ADDRESS & ZIP CODE
CHECK (if applicable)
■ Civilian
■ Military
FEDERAL AGENCY AND OFFICE
AMOUNT
MILITARY PAYROLL
Branch of Service?________________
CIVILIAN PAYROLL
CASH/CHECK
Check Number:
INTERVAL
SOCIAL SECURITY NUMBER /EMPLOYEE ID
WORK PHONE NUMBER
(
CONTRIBUTION: Fill in the blank showing the amount of your payroll allotment, cash or check contribution.
Write in the total of your annual contribution in the space provided.
ALLOTMENT SOURCE
0481 27 6330
)
CHARITY CODE
ANNUAL AMOUNT
TOTAL GIFT
X 12 months
$
X 26 pay periods
$
Cash/Check Amount:
$
(make check payable to the Combined Federal Campaign)
CFC Organizations do not provide goods or services in whole or partial consideration for any
contributions made to the organizations via this pledge card.
INFORMATION RELEASE (OPTIONAL)
Any information you enter below will be released, along with your name, to the
charity(ies) to which you made a pledge. Do not enter your work address or email.
Home Address
_____________________________________________
_____________________________________________
Personal Email Address
_____________________________________________
■ In addition to my contact information, I authorize the CFC to release the amount
of my pledge to the charity(ies) I designated above.
www.northernlightscfc.org
DESIGNATED GIFT: To designate one or more charities or federated groups, fill in the
charity code(s) and dollar amounts above. Undesignated gifts are distributed among all
organizations in proportion to their pledges.
PAYROLL DEDUCTION AUTHORIZATION
I hereby authorize any agency of the United States Government by which I may be employed during 2016
to deduct the amount(s) shown above from my pay each pay period during the calendar year 2016 starting
with the first pay period that begins in January and ending with the last pay period that begins in December,
and to pay the amounts so deducted to the Combined Federal Campaign shown above. I understand that
this authorization may be revoked by me in writing at any time before it expires.
SIGNATURE _______________________________________________ DATE ___________________________
OPM FORM 1654 REV. MAY 2015
COPY #2 TO THE CENTRAL RECEIPT POINT
PLEASE USE BALLPOINT PEN AND WRITE FIRMLY
PRINT NAME (LAST)
CFC Campaign No. City/State Code: ATTENTION PAYROLL OFFICES:
Only use this number to identify
the local campaign.
1619 Dayton Ave, Suite 323, St. Paul, MN 55104
PLEASE USE BALLPOINT PEN AND WRITE FIRMLY
PRINT NAME (LAST)
FIRST
MIDDLE INITIAL
WORK ADDRESS & ZIP CODE
CHECK (if applicable)
■ Civilian
■ Military
FEDERAL AGENCY AND OFFICE
AMOUNT
MILITARY PAYROLL
Branch of Service?________________
CIVILIAN PAYROLL
CASH/CHECK
Check Number:
INTERVAL
0481 27 6330
SOCIAL SECURITY NUMBER /EMPLOYEE ID
WORK PHONE NUMBER
(
CONTRIBUTION: Fill in the blank showing the amount of your payroll allotment, cash or check contribution.
Write in the total of your annual contribution in the space provided.
ALLOTMENT SOURCE
CFC Campaign No. City/State Code: ATTENTION PAYROLL OFFICES:
Only use this number to identify
the local campaign.
)
CHARITY CODE
ANNUAL AMOUNT
TOTAL GIFT
X 12 months
$
X 26 pay periods
$
Cash/Check Amount:
$
(make check payable to the Combined Federal Campaign)
CFC Organizations do not provide goods or services in whole or partial consideration for any
contributions made to the organizations via this pledge card.
INFORMATION RELEASE (OPTIONAL)
Any information you enter below will be released, along with your name, to the
charity(ies) to which you made a pledge. Do not enter your work address or email.
Home Address
_____________________________________________
_____________________________________________
Personal Email Address
_____________________________________________
■ In addition to my contact information, I authorize the CFC to release the amount
of my pledge to the charity(ies) I designated above.
www.northernlightscfc.org
DESIGNATED GIFT: To designate one or more charities or federated groups, fill in the
charity code(s) and dollar amounts above. Undesignated gifts are distributed among all
organizations in proportion to their pledges.
PAYROLL DEDUCTION AUTHORIZATION
I hereby authorize any agency of the United States Government by which I may be employed during 2016
to deduct the amount(s) shown above from my pay each pay period during the calendar year 2016 starting
with the first pay period that begins in January and ending with the last pay period that begins in December,
and to pay the amounts so deducted to the Combined Federal Campaign shown above. I understand that
this authorization may be revoked by me in writing at any time before it expires.
SIGNATURE _______________________________________________ DATE ___________________________
OPM FORM 1654 REV. MAY 2015
COPY #3 CONTRIBUTOR TO KEEP THIS COPY FOR PERSONAL TAX RECORDS
NORTHERN LIGHTS COMBINED FEDERAL CAMPAIGN
Privacy Act Notice
Executive Order No. 12353 authorizes the U.S. Office of Personnel Management to conduct fund raising activities and to establish
procedures for collecting information related to such activities.
Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security Number (SSN). This collected information will
be disclosed to organizations maintaining the accounting of contributions and to your payroll office.
Additional disclosure may be made to the Department of Treasury to make proper financial adjustments to a court or another agency
when the government is party to a suit; and to the Internal Revenue Service and state and local taxing authorities regarding income
tax returns.
The furnishing of the SSN, along with other data requested, is voluntary. However, failure to furnish any of the requested information
may result in errors or noncompliance with your request for a payroll deduction by your agency.
If you are making a one-time, lump-sum gift and, therefore, not using the payroll deduction method of payment, you are not required
to furnish your SSN.