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Home > About Unity > Unity Health Foundation > Capital Campaign Employee Payroll Deduction Form 
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Capital Campaign Payroll Deduction Form

PRiSM Leadership Levels:   Amount Pledged     Unity Employee Deduction Per 25 pay periods
  Benefactor   $5,000   $200
  Patron   $2,500   $100
  Member   $1,000   $40
Additional Giving Levels:  
  Partner   $500   $20
  Associate   $250   $10
  Friend   $100   $4
  Supporter   $50   $2
  Contributor   $25   $1
  Other   $____    

Thank you for your contribution!
Please fill out the following information (* indicates required information).  Your payroll deduction will begin the pay period after we receive your pledge.

*First Name:
*Last Name:
*Email Address:
*Phone Number:
*Total Gift Amount: US$
*Are you an ACM Laboratory employee? Yes No
Unity Facility or Department:

Please know that your gift will go directly to help enhance the services we provide to the patients and residents we serve.

Your contribution is tax-deductible to the extent of the law.  You will receive an acknowledgment and receipt of your gift for tax purposes.

Thank you for your support!