MGI Payroll Deduction

Major Giving Initiative Registration

We are aiming for 100% participation from our Tri-State Family toward the Major Giving Initiative. Employees now have the opportunity to double their dollars with two anonymous donors who have offered to match up to $50,000 in employee donations! Please consider giving any amount to show your support of the new wing.
I give Tri-State Memorial Hospital & Medical Campus authorization to deduct the following amount on an annual basis: (please check the box below that coincides with your donation, then specify the amount to be given)
Type of Donation:

Dollars per pay periodOne time donation on the 1st pay period in JanuaryPaid time off hours
If donating per pay period, below is how much your donation equivilatent to for 1 year (or 26 pay periods)
- $2 = $52
- $4 = $104
- $5 = $130
- $10 = $260
- $15 = $390
- $20 = $520
- $25 = $650
- $30 = $780
- $35 = $910
- $40 = $1,040
- $42 = $1,092
- $45 = $1,170
- $50 = $1,300
Please specify the amount of dollars per pay period, one time donation, or hours of paid time off that you wish to donate:
Would you like to keep your donation anonymous?

YesNo
Name

First Name Last Name
Department:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
By clicking submit you are authorizing Tri-State Memorial Hospital & Medical campus to deduct your chose of either a specified amount dollars per pay period, a one-time donation the first pay period in January, or a specified amount of paid time off hours. The information that you are authorizing is outlined in this form above.
Should be Empty:

Major Giving Initiative Registration