Pledge – AltaMed Gives

Employee Giving Pledge Form

Employee Information

Name *

Preferred Pronoun

EE ID# *

Email Address*

Work Location *

Work Department *

Solicitor (Giving Ambassador)

Address

Tax acknowledgement will be sent to the address listed below

Street *

City *

State *

Zip Code *

Step 1: Choose the program(s) you want to support

You can pick many programs as you wish to support

Area of greatest need - Employee Giving Committee will decide where the dollars are needed the most.
Immediate Needs Fund - Assists patients/participants who do not have access to basic necessities that affect their health and well-being.

Step 2: Tell us how much and how many installments

Your donation amount will be split evenly amongst all the programs you select to support.

A. Ongoing deduction (Recurring pay periods)

Recurring Donation per pay period

$ / pay period

Recurring Pay Periods

B. 2021 commitment

Donation per pay period x 26 pay periods

$ / pay period

26 Pay Periods

C. One-time deduction

Donation per pay period x 1 pay period

1 Pay Period

TOTAL DONATION AMOUNT

If you selected option A, recurring payments, the total amount is the dollar amount per pay period that will be deducted and does not reflect the total donation you will make.

Total Amount

Make this gift anonymous

Acknowledgement

I acknowledge that I am instructing AltaMed Health Services Corporation to make automatic payroll deductions for my participation in the employee giving program. I understand I can modify or cancel my participation at any time in the future.
I understand that my authorized deduction will stay in place for the length of time I have designated above unless I inform the Development department in writing of my decision to modify or cancel the deductions. There are no reimbursements once a deduction has been made.
I understand that my participation in the employee giving program is completely voluntary and that I will not receive compensation or benefits for my participation.

Please enter your full name below to confirm your participation in the program: *

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Thank you for your pledge!

Your contributions are tax deductible to the extent permitted by law. Tax ID # 95-2810095
There are no reimbursements once a deduction has been taken.

Note: Payroll deductions will always start with the beginning of a new pay period.

For all program inquiries, changes to pledge amounts or cancellation of pledge please email the Development Department at [email protected]