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Payroll/PTO Deduction
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Payroll/PTO Deduction
If you have a website login from The Children's Hospital Foundation, you can
Click here
to autofill this form
* required information
Contact
Employee Contact Information
Employee ID Number:
*
Title:
*
-- please make a selection --
Mr.
Ms.
Mrs.
Miss
Dr.
First Name:
*
Middle Initial:
Last Name:
*
Suffix:
Email:
*
Address Line 1:
*
Address Line 2:
City:
*
State:
*
-- please make a selection --
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ZIP/Postal Code:
*
Business Phone:
*
Phone:
Fax:
Donation Information
Become a Miracle Maker by making a minimum donation of $7 per pay period or $180 (one-time).
Recurring Payroll Deduction of:
$
One-time Payroll Deduction of:
$
PTO Donation: this many hours:
Deductions will begin 3/12/2010. Please call 720-777-1700 to cancel.
The dollar amount of your PTO donation will be added to your taxable gross income. For more information, please contact payroll.