ATTENTION PAYROLL OFFICES: Only use this number to identify the local campaign. CFC Campaign Number Enter Last Name, First Name, and MI Check (if applicable) Federal Agency and Office SSN/ Employee ID Work Phone Number Work Address & Zip Code 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 AMOUNT INTERVAL TOTAL GIFT Charity Code Annual Amount $ MILITARY PAYROLL Branch of Service? $ Civilian Payroll X 12 months $0.00 $ $ X 26 months $0.00 $ Check / Cash Amt.: $ Check Number: (make check payable to the Combined Federal Campaign) $ $ Date of Contribution: CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to the organizations via this pledge card. DESIGNATED GIFT: To designate to one or more charities or federated groups, fill in the charity code(s) and dollar amounts above. RECOGNITION OPTIONS *Only checked options will be processed.* *Address information is required to receive an acknowledgment from the charity.* My check-mark(s) and completed information below authorize the CFC to release my name and the corresponding information to my designated charities: Pledge Amount: Home Address Home E-mail: PAYROLL DEDUCTION AUTHORIZATION I hereby authorize any agency of the United States Government by which I may be employed during 2010 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2010 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 See reverse side for information on volunteer opportunities in your community. OPM 1654 Revised March 2009 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com COPY #1 – PAYROLL OFFICE PLEASE USE BALL POINT PEN & WRITE FIRMLY Civilian Military ATTENTION PAYROLL OFFICES: Only use this number to identify the local campaign. CFC Campaign Number Enter Last Name, First Name, and MI Check (if applicable) Federal Agency and Office SSN/ Employee ID Work Phone Number Work Address & Zip Code 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 AMOUNT INTERVAL TOTAL GIFT Charity Code Annual Amount $ MILITARY PAYROLL Branch of Service? $ Civilian Payroll X 12 months $0.00 $ $ X 26 months $0.00 $ Check / Cash Amt.: $ Check Number: (make check payable to the Combined Federal Campaign) $ $ Date of Contribution: CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to the organizations via this pledge card. DESIGNATED GIFT: To designate to one or more charities or federated groups, fill in the charity code(s) and dollar amounts above. RECOGNITION OPTIONS *Only checked options will be processed.* *Address information is required to receive an acknowledgment from the charity*. My check-mark(s) and completed information below authorize the CFC to release my name and the corresponding information to my designated charities: Pledge Amount: Home Address Home E-mail: PAYROLL DEDUCTION AUTHORIZATION I hereby authorize any agency of the United States Government by which I may be employed during 2010 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2010 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 See reverse side for information on volunteer opportunities in your community. OPM 1654 Revised March 2009 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com COPY #2 – For Central Receipt Point PLEASE USE BALL POINT PEN & WRITE FIRMLY Civilian Military ATTENTION PAYROLL OFFICES: Only use this number to identify the local campaign. CFC Campaign Number Enter Last Name, First Name, and MI Check (if applicable) Federal Agency and Office SSN/ Employee ID Work Phone Number Work Address & Zip Code 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 AMOUNT INTERVAL TOTAL GIFT Charity Code Annual Amount $ MILITARY PAYROLL Branch of Service? $ Civilian Payroll X 12 months $0.00 $ $ X 26 months $0.00 $ Check / Cash Amt.: $ Check Number: (make check payable to the Combined Federal Campaign) $ $ Date of Contribution: CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to the organizations via this pledge card. DESIGNATED GIFT: To designate to one or more charities or federated groups, fill in the charity code(s) and dollar amounts above. RECOGNITION OPTIONS *Only checked options will be processed.* *Address information is required to receive an acknowledgment from the charity.** My check-mark(s) and completed information below authorize the CFC to release my name and the corresponding information to my designated charities: Pledge Amount: Home Address Home E-mail: PAYROLL DEDUCTION AUTHORIZATION I hereby authorize any agency of the United States Government by which I may be employed during 2010 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2010 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 See reverse side for information on volunteer opportunities in your community. OPM 1654 Revised March 2009 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com COPY #3 – Contributor's Copy- Keep For Personal Tax Records PLEASE USE BALL POINT PEN & WRITE FIRMLY Civilian Military 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. Find a Volunteer Opportunity The USA Freedom Corps Volunteer Network can help you access service opportunities near your home or office, across the country, or overseas. Just go to www.volunteer.gov, enter geographic information, such as zip code or state, and your area of interest to find out how you can get involved. American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4