Fillable Benevolent Fund Form printable pdf download

Benevolent Fund Form

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Pledge Form

Employee Name: ___________________________________________________________________________________

(please print your full name)

Employee #: __________________________________________

Blazer ID: _________________________________

(this number may be located on your payslip)

Campus Department:__________________________________

Campus Address:___________________________

Campus Phone:_______________________________________

E-mail:____________________________________

Signature: ___________________________________________

Date:_____________________________________

Please circle your payroll:

UAB

Health System

HSF

Callahan

VIVA

_____ Please check here if you are changing your gift type/amount.

Continuous Giver

through payroll deduction

1 HOUR PAY PER MONTH:

Fairshare Giver

_____ Check this option if you’d like to donate one (1) hour of your pay per month.

1 PERCENT PAY PER MONTH:

Fairshare Giver

_____ Check this option if you’d like to donate one (1) percent of your pay per month.

FIXED AMOUNT PER MONTH:

Good Faith Giver

_____ Check this option if you’d like to donate a fixed amount of your choice.

$________/month

(specify amount)

Leadership Giver

through payroll deduction or one time gift ($1,000 or more per year)

Select one of the following if you’d like to give at this level, or increase your Leadership Gift:

_____ $84.00/month

$________/month

($1,000/yr)

(specify amount)

payroll deduction

Initial here if you do not want to be recognized in publicity as a Leadership Giver by Benevolent Fund or United Way: ________

If you ‘d like to include your spouse in your gift, print name(s) for publicity:___________________________________________

One Time Gift

Please indicate the amount of your One Time Gift: $________

(specify amount)

Please circle your preferred method for this gift:

Payroll deduction

Attached cash

Attached check #_________________

(include check number)

Gift Designation

1. _____________________

You may designate your gift to a maximum of three (3) agencies. Please enter the name

and three digit code assigned to each agency in the Benevolent Fund brochure or on

2. _____________________

the Benevolent Fund’s website. If you’d like for your donation to be used for Employee

Emergency Assistance Program or Independent Agencies (supported agencies without

3. _____________________

designation codes) please use code #000.

Please return this form to the Benevolent Fund office:

Campus address: AB B-84, zip 0100

Office number: 934-1581

Fax number: 975-9608

E-mail: benevolentfund@uab.edu

Benevolent Fund Form

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