CFC Campaign Number †Civilian †Military Last Name, First Name, MI Federal Agency and Office Work Address & ZIP Code SSN/Employee ID Work Phone Number 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 MILITARY PAYROLL Branch of Service? CHARITY CODE ANNUAL AMT $ $ x 12 months $ $ x 26 pay periods $ $ CIVILIAN PAYROLL $ CASH/CHECK $ Amount: $ Check Number: $ (make check payable to the Combined Federal Campaign) CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to DESIGNATED GIFT: To designate to one or more charities or federated groups, fill in the charity code(s) and dollar amounts above. Undesignated the organizations via this pledge card. gifts are distributed among all organizations in proportion to their pledges. INFORMATION RELEASE (OPTIONAL) Any information you enter below will be released, along with your name, to the charity(ies) to PAYROLL DEDUCTION AUTHORIZATION which you made a pledge. Do not enter your work address or email. Home Address: I hereby authorize any agency of the United States Government by which I may be employed during 2013 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2013 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. Personal Email Address: † In addition to my contact information, I authorize the CFC to release the amount of my pledge to the charity(ies) I designated above. Signature Date OPM 1654 Revised April 2012 American LegalNet, Inc. www.FormsWorkFlow.com COPY #1 - PAYROLL OFFICE PLEASE USE BALL POINT PEN & WRITE FIRMLY ATTENTION PAYROLL OFFICES: Use this number only to identify the local campaign. City/State Code: CFC Campaign Number †Civilian †Military Last Name, First Name, MI Federal Agency and Office Work Address & ZIP Code Work Phone Number 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 MILITARY PAYROLL Branch of Service? CHARITY CODE ANNUAL AMT $ $ x 12 months $ $ x 26 pay periods $ $ CIVILIAN PAYROLL $ CASH/CHECK $ Amount: $ Check Number: $ (make check payable to the Combined Federal Campaign) CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to DESIGNATED GIFT: To designate to one or more charities or federated groups, fill in the charity code(s) and dollar amounts above. Undesignated the organizations via this pledge card. gifts are distributed among all organizations in proportion to their pledges. INFORMATION RELEASE (OPTIONAL) Any information you enter below will be released, along with your name, to the charity(ies) to PAYROLL DEDUCTION AUTHORIZATION which you made a pledge. Do not enter your work address or email. Home Address: I hereby authorize any agency of the United States Government by which I may be employed during 2013 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2013 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. Personal Email Address: † In addition to my contact information, I authorize the CFC to release the amount of my pledge to the charity(ies) I designated above. Signature Date OPM 1654 Revised April 2012 American LegalNet, Inc. www.FormsWorkFlow.com COPY #2 - CENTRAL RECEIPT POINT PLEASE USE BALL POINT PEN & WRITE FIRMLY ATTENTION PAYROLL OFFICES: Use this number only to identify the local campaign. City/State Code: †Civilian †Military Last Name, First Name, MI PLEASE USE BALL POINT PEN & WRITE FIRMLY ATTENTION PAYROLL OFFICES: Use this number only to identify the local campaign. City/State Code: Federal Agency and Office Work Address & ZIP Code Work Phone Number 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 MILITARY PAYROLL Branch of Service? CHARITY CODE ANNUAL AMT $ $ x 12 months $ $ x 26 pay periods $ $ CIVILIAN PAYROLL $ CASH/CHECK $ Amount: $ Check Number: $ (make check payable to the Combined Federal Campaign) CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to DESIGNATED GIFT: To designate to one or more charities or federated groups, fill in the charity code(s) and dollar amounts above. Undesignated the organizations via this pledge card. gifts are distributed among all organizations in proportion to their pledges. INFORMATION RELEASE (OPTIONAL) Any information you enter below will be released, along with your name, to the charity(ies) to PAYROLL DEDUCTION AUTHORIZATION which you made a pledge. Do not enter your work address or email. Home Address: I hereby authorize any agency of the United States Government by which I may be employed during 2013 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2013 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. Personal Email Address: † In addition to my contact information, I authorize the CFC to release the amount of my pledge to the charity(ies) I designated above. Signature Date OPM 1654 Revised April 2012 American LegalNet, Inc. www.FormsWorkFlow.com COPY #3 - CONTRIBUTOR'S COPY - KEEP FOR PERSONAL TAX RECORDS CFC Campaign Number COPY #3 - CONTRIBUTOR'S COPY - KEEP FOR PERSONAL TAX RECORDS 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