Employee Contribution Request - Payroll Deduction

All donations are viewed as charitable contributions for federal income purposes (state, local and social security / Medicare tax law may vary – please see a tax consultant for information specific to your situation).

Location *

First Name *

Last Name *

Last 4 of SSN *

E-mail Address *

Frequency of Deduction *

Give Once

Give per Paycheck

Contribution Amount *

Effective Date * +

I am requesting the entered amount to be deducted from all future scheduled paychecks and deposited into the ProAmpac Employee Assistance Fund as of the provided effective date until further notice :

I am requesting the entered one-time deduction amount be deducted from my next scheduled paycheck and deposited into the ProAmpac Employee Assistance Fund :

Signature *

clear

Request Date * +