UPMC Children’s Hospital Foundation
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Payroll Deduction
Employee and Professional Staff Payroll Deduction Form
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*
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INFORMATION FOR ONLINE PAYROLL DEDUCTION SURVEY
Title:
Dr.
Miss
Mr.
Mrs.
Ms.
First Name:
*
Last Name:
*
Address 1:
*
Address 2:
City:
*
State:
*
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip:
*
Cell Phone:
Email Address:
*
Employee ID:
*
Employee Cost Center/Department:
$ Amount to be deducted per pay. (Payroll deduction gifts will be renewed automatically on an annual basis unless you contact the Foundation to stop payments.)
*
Gift Designation:
Children's Hospital Fund
Children's Trust
Adolescent Medicine (OTR)
Anesthesiology (OTR)
Asthma & Allergy (OTR)
Audiology and Speech (OTR)
Cardiology (OTR)
Child Advocacy (OTR)
Critical Care (OTR)
Cystic Fibrosis (OTR)
Dermatology (OTR)
Emergency Services (OTR)
Endocrinology (OTR)
Gasto Motility (OTR)
Gastroenterology (OTR)
Genetics (OTR)
Hearing Center (OTR)
Hematology & Oncology (OTR)
IBD Center (OTR)
Infant Stroke Program (OTR)
Neurology (OTR)
Neurooncology (OTR)
Neurosurgery (OTR)
Orthopaedics (OTR)
Pediatric Diabetes (OTR)
Pediatric General Surgery (OTR)
Pediatric Otolaryngology (OTR)
Plastic Surgery (OTR)
Primary Care Center (OTR)
program for NFRD (OTR)
Sickle Cell (OTR)
Trauma (OTR)
Urology (OTR)
<Enter your own value>
Enter your own value
(Optional) This gift is made
In Honor of
In Memory of
On the Occasion of
of
Please send a letter of notification to:
Address:
City:
State:
*
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip:
Relationship of the person above to person honored/remembered:
Please include the following message in the letter:
I prefer to make this donation anonymously:
I prefer to make this donation anonymously:
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