Payroll Deduction Stakeholder Name:* First Last Employee ID Number*Facility:*Please choose from the following choices* I am a NEW hire who wishes to take the following action for the Compassion Fund I am an already employed stakeholder who wishes to take the following action for the Compassion Fund Please fill out the information below:* I wish to enroll in automatic payroll deductions to the Compassion Fund, Inc., a 501(c)(3) tax exempt organization, in the amount set forth below: Amount of Deduction Per Pay Period (initial under desired item)* $1 $2 $5 $10 $15 $20 $30 Other Other*What would you like to contribute?By signing below, I authorize Stakeholder Payroll Services, LLC to make the above specified changes from the wages due to me for each payroll period from the date of this authorization. I understand also that it may take up to a full payroll period for changes I make via the form to take effect. A facsimile or electronic submission of this form shall have the same validity as the original.*Date Date Format: MM slash DD slash YYYY
