Bon Secours Mercy Health Foundation

Payroll Deduction

Give Payroll Deduction

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This form allows you to make a gift via payroll deduction. If you would rather give by credit card, visit the credit card form »

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Question - Required - Yes! I want to Give for Good! My level:

Power Hour (1 hour per pay period) *

Half Hour Hero (1/2 hour per pay period) *

Lead for Good = $1,000 ($38.47 per pay period) *

Lead for Good = $1,000 (one-time payroll deduction)

$_________ per pay period

$_________ one-time payroll deduction

None of the above

Question - Not Required - Amount per paycheck $

Question - Not Required - Amount of one-time payroll deduction $

*Your pay period gift will be recurring, meaning it will continue each year, unless you decide to stop or change the amount of your gift.

Question - Not Required - You may opt-out of recurring giving below. If you prefer to opt-out of recurring giving, so your per pay period gift will stop after 12/31/2021, select YES below.

Yes - Please stop my gift after 12/31/2021

No - Allow my gift to continue indefinitely

Donor Information

Your information:


*	Title:
*	First Name: Required
	Middle Name:
*	Last Name: Required
	Suffix:
	Professional Suffix:
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
*	State / Province: Required
*	ZIP / Postal Code: Required
*	Phone Number: Required
	Date of Birth:	Date of Birth:
	If you respond and have not already registered, you will receive periodic updates and communications from Bon Secours Mercy Health Foundation.

*

Question - Required - Phone type

*

Question - Required - Associate ID#

Question - Not Required - AHPR

Choose a Special Purpose / Gift Designation

(Total of all selections must equal 100%)

Note: When selecting your market's corresponding fund you may need to scroll all the way down to find your market’s funds.

Question - Not Required - Choose a Market

Question - Not Required - Choose a Fund

Question - Not Required - Amount (%)

Question - Not Required - Choose a Market:

Question - Not Required - Choose a Fund:

Question - Not Required - Amount (%)

Question - Not Required - Choose a Market:

Question - Not Required - Choose a Fund:

Question - Not Required - Amount (%):

Question - Not Required - Choose a Market:

Question - Not Required - Choose a Fund:

Question - Not Required - Amount (%):

Question - Not Required - Choose a Market:

Question - Not Required - Choose a Fund:

Question - Not Required - Amount (%):

Question - Not Required - Custom Fund

I would like to enter details about a fund or designation not already listed.

Question - Not Required - Market and Fund Name:

Question - Not Required - Amount (%):

Question - Not Required - Gift Calculation

Question - Not Required - For internal use only

Payroll Deduction

Give Payroll Deduction

Donor Information

Choose a Special Purpose / Gift Designation

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