Primary Promise for Caregivers

Per Paycheck Payroll Donation Form

This form is used to make a contribution from your paycheck every pay period. This is a recurring charge that will deduct the amount you specify every 2 weeks. Payroll deductions will start within 30 days after you submit this form.

If you are currently donating via payroll deduction, anything you select on this form will replace your current deduction. If you are happy with your current deduction, you do not need to complete this form. Thank you!

Title:

* must provide value

First Name:

* must provide value

Last Name:

* must provide value

Email Address:

* must provide value

Address Line 1:

* must provide value

Address Line 2:

City:

* must provide value

State:

* must provide value

Zip Code:

* must provide value

Employee ID:

* must provide value

Employee Facility:

* must provide value

Employee Department:

* must provide value

Where would you like to donate?

Select a maximum of three different designations for your payroll deduction gift. All deductions will continue every year until you ask Intermountain Foundation to stop.

Please choose your cause area for this gift:

* must provide value

Amount per paycheck:

* must provide value

Second Designation

Yes

reset

Please choose your cause area for this gift:

* must provide value

Amount per paycheck:

* must provide value

Third Designation

Yes

reset

Please choose your cause area for this gift:

* must provide value

Amount per paycheck:

* must provide value

Please sign to confirm your payroll deduction pledge

* must provide value

Add signature

Today's Date:

* must provide value

M-D-Y

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.