Confidential Employee Payroll Deduction Form Employee Name* First Last Department* Work Phone*Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Phone*How would you like your name to appear in our Annual Report and on the Employee Plaque? Anonymous: Please do not list my name for public recognition. Anonymous: Please do not list my name for public recognition. Which Funds would you like to support?* MCH Unrestricted Fund Reach Out and Read Fund Employee Resilience Committee Peter L. Gosline Employee Scholarship Fund Bi-Weekly Payroll DeductionMCH Unrestricted Fund$1 per pay period/$26 Total Annual Gift$2 per pay period/ $52 Total Annual Gift$3 per pay period/ $78 Total Annual Gift$4 per pay period/ $104 Total Annual Gift$5 per pay period/ $130 Total Annual Gift$10 per pay period/ $260 Total Annual Gift$15 per pay period/ $390 Total Annual Gift$20 per pay period/ $520 Total Annual GiftOtherIf other please specify Bi-Weekly Payroll DeductionReach Out and Read Fund$1 per pay period/$26 Total Annual Gift$2 per pay period/ $52 Total Annual Gift$3 per pay period/ $78 Total Annual Gift$4 per pay period/ $104 Total Annual Gift$5 per pay period/ $130 Total Annual Gift$10 per pay period/ $260 Total Annual Gift$15 per pay period/ $390 Total Annual Gift$20 per pay period/ $520 Total Annual GiftOtherIf other please specify Bi-Weekly Payroll DeductionEmployee Resilience Committee$1 per pay period/$26 Total Annual Gift$2 per pay period/ $52 Total Annual Gift$3 per pay period/ $78 Total Annual Gift$4 per pay period/ $104 Total Annual Gift$5 per pay period/ $130 Total Annual Gift$10 per pay period/ $260 Total Annual Gift$15 per pay period/ $390 Total Annual Gift$20 per pay period/ $520 Total Annual GiftOtherIf other please specify Bi-Weekly Payroll DeductionPeter L. Gosline Employee Scholarship Fund$1 per pay period/$26 Total Annual Gift$2 per pay period/ $52 Total Annual Gift$3 per pay period/ $78 Total Annual Gift$4 per pay period/ $104 Total Annual Gift$5 per pay period/ $130 Total Annual Gift$10 per pay period/ $260 Total Annual Gift$15 per pay period/ $390 Total Annual Gift$20 per pay period/ $520 Total Annual GiftOtherIf other please specify Make my Gift to MCH through payroll deduction.* Yes No Payroll Deductions will begin the first pay period in April and will continue for 26 pay periods.Thank you for your pledge through payroll deductions! In appreciation of your gift, we would like to offer you a "We are all in this together" Long sleeve shirt. If you would like to receive a shirt, please select your size:Please selectSmallMediumLargeXLXXL3XL4XLNo Shirt PleaseHonor / Memory I/We would like to make my gift in honor someone. I/We would like to make my gift in memory of someone. I/We would like my gift to be in Honor of: I/We would like my gift to be in Memory of: Consent* By submitting this form, I agree to the information submitted If you would like to make a one-time gift: Please make checks payable to MCH Employee Giving Campaign and send them to the Philanthropy Department or visit Donate Online Now - Monadnock Community Hospital to make a gift with a credit card. If you have questions, please call LeeAnn Moore at x1700.
