New York City Combined Federal Campaign For more information visit nyccfc.org

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1 I make it possible New York City Combined Federal Campaign For more information visit nyccfc.org

2 A stronger community, more resilient families, healthier lives, promising futures, an improved world.your generous gift to CFC makes it possible. Thank you! Prefer to make your pledge online? Go to to find your charity s five digit codes, and make your pledge through payroll deduction, credit card or e-check through EEX, MyPay or CFC Nexus. Payroll deduction makes it easy to give and will have a significant impact on the charities you select. Below are common payroll pledge amounts per pay period. Civilian $40 x 26 = $1040 Military $100 x 12 = $1200 $20 x 26 = $520 $50 x 12 = $600 $12 x 26 = $312 $25 x 12 = $300 $6 x 26 = $156 $12 x 12 = $144 Questions? Go to for instructions and to search charities or call the CFC Office at $80 per pay period can help provide injured veterans with physical rehabilitation and emotional support $50 per pay period supports clinical research to cure cancer, diabetes, autism and other diseases $40 per pay period saves eight acres of tropical rain forest $20 per pay period trains volunteers to advocate for abused and neglected children $12 per pay period shelters and feeds a family devastated by a natural disaster $6 per pay period delivers weekly home health care to a fragile senior so she can remain at home

3 NEW YORK CITY COMBINED FEDERAL CAMPAIGN 1370 Broadway, 5th Floor, New York, NY CFC Campaign No City/State Code: ATTENTION PAYROLL OFFICES: Only use this number to identify the local campaign. PRINT NAME (LAST) FIRST MIDDLE INITIAL CIVILIAN FEDERAL AGENCY AND OFFICE SOCIAL SECURITY NUMBER/EMPLOYEE ID MILITARY PLEASE USE BALL POINT PEN & WRITE FIRMLY WORK ADDRESS & ZIP CODE CONTRIBUTION: Please check one of the boxes or fill in the blank showing the amount of your payroll allotment, cash or check contribution. Write in the total annual contribution in the space provided. CHARITY CODE WORK PHONE NUMBER ( ) ANNUAL AMOUNT MILITARY Branch of Service? CIVILIAN x 12 pay periods = x 26 pay periods = $ x 12 pay periods = $2, $78.00 x 26 pay periods = $2, $ x 12 pay periods = $1, $40.00 x 26 pay periods = $1, $50.00 x 12 pay periods = $ $20.00 x 26 pay periods = $ $25.00 x 12 pay periods = $ $10.00 x 26 pay periods = $ $15.00 x 12 pay periods = $ $6.00 x 26 pay periods = $ Cash/Check Amount: Check # Cash/Check Amount: Check # Make check payable to the Combined Federal Campaign Make check payable to the Combined Federal Campaign DESIGNATED GIFT: To designate one or more charities or federated groups, fill in the CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to the organizations via this pledge card. Date of Contribution: charity code(s) and dollar amounts above. Undesignated gifts are distributed among all organizations in proportion to their pledges. INFORMATION RELEASE (OPTIONAL) Any information you enter below will be released, along with your name, to the charity(ies) to which you made a pledge. Do not enter your work address or . Home Address Personal Address PAYROLL DEDUCTION AUTHORIZATION I hereby authorize any agency of the United States Government by which I may be employed during 2015 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2015 starting with the first pay period that begins in January and ending with the last pay period that begins in December, and to pay the amounts so deducted to the Combined Federal Campaign shown above. I understand that this authorization may be revoked by me in writing at any time before it expires. COPY #1 PAYROLL OFFICE In addition to my contact information, I authorize the CFC to release the amount of my pledge to the charity(ies) I designated above. SIGNATURE DATE OPM FORM 1654 REVISED MAY 2014

4 NEW YORK CITY COMBINED FEDERAL CAMPAIGN 1370 Broadway, 5th Floor, New York, NY CFC Campaign No City/State Code: ATTENTION PAYROLL OFFICES: Only use this number to identify the local campaign. PRINT NAME (LAST) FIRST MIDDLE INITIAL CIVILIAN FEDERAL AGENCY AND OFFICE SOCIAL SECURITY NUMBER/EMPLOYEE ID MILITARY PLEASE USE BALL POINT PEN & WRITE FIRMLY WORK ADDRESS & ZIP CODE CONTRIBUTION: Please check one of the boxes or fill in the blank showing the amount of your payroll allotment, cash or check contribution. Write in the total annual contribution in the space provided. INFORMATION RELEASE (OPTIONAL) Any information you enter below will be released, along with your name, to the charity(ies) to which you made a pledge. Do not enter your work address or . Home Address Personal Address CHARITY CODE WORK PHONE NUMBER ( ) MILITARY Branch of Service? CIVILIAN x 12 pay periods = x 26 pay periods = $ x 12 pay periods = $2, $78.00 x 26 pay periods = $2, $ x 12 pay periods = $1, $40.00 x 26 pay periods = $1, $50.00 x 12 pay periods = $ $20.00 x 26 pay periods = $ $25.00 x 12 pay periods = $ $10.00 x 26 pay periods = $ $15.00 x 12 pay periods = $ $6.00 x 26 pay periods = $ Cash/Check Amount: Check # Cash/Check Amount: Check # Make check payable to the Combined Federal Campaign Make check payable to the Combined Federal Campaign DESIGNATED GIFT: To designate one or more charities or federated groups, fill in the CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to the organizations via this pledge card. Date of Contribution: charity code(s) and dollar amounts above. Undesignated gifts are distributed among all organizations in proportion to their pledges. PAYROLL DEDUCTION AUTHORIZATION ANNUAL AMOUNT I hereby authorize any agency of the United States Government by which I may be employed during 2015 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2015 starting with the first pay period that begins in January and ending with the last pay period that begins in December, and to pay the amounts so deducted to the Combined Federal Campaign shown above. I understand that this authorization may be revoked by me in writing at any time before it expires. COPY #2 TO THE CFC OFFICE In addition to my contact information, I authorize the CFC to release the amount of my pledge to the charity(ies) I designated above. SIGNATURE DATE OPM FORM 1654 REVISED MAY 2014

5 NEW YORK CITY COMBINED FEDERAL CAMPAIGN 1370 Broadway, 5th Floor, New York, NY CFC Campaign No City/State Code: ATTENTION PAYROLL OFFICES: Only use this number to identify the local campaign. PRINT NAME (LAST) FIRST MIDDLE INITIAL CIVILIAN FEDERAL AGENCY AND OFFICE SOCIAL SECURITY NUMBER/EMPLOYEE ID MILITARY PLEASE USE BALL POINT PEN & WRITE FIRMLY WORK ADDRESS & ZIP CODE CONTRIBUTION: Please check one of the boxes or fill in the blank showing the amount of your payroll allotment, cash or check contribution. Write in the total annual contribution in the space provided. INFORMATION RELEASE (OPTIONAL) Any information you enter below will be released, along with your name, to the charity(ies) to which you made a pledge. Do not enter your work address or . Home Address Personal Address CHARITY CODE WORK PHONE NUMBER ( ) ANNUAL AMOUNT MILITARY Branch of Service? CIVILIAN x 12 pay periods = x 26 pay periods = $ x 12 pay periods = $2, $78.00 x 26 pay periods = $2, $ x 12 pay periods = $1, $40.00 x 26 pay periods = $1, $50.00 x 12 pay periods = $ $20.00 x 26 pay periods = $ $25.00 x 12 pay periods = $ $10.00 x 26 pay periods = $ $15.00 x 12 pay periods = $ $6.00 x 26 pay periods = $ Cash/Check Amount: Check # Cash/Check Amount: Check # Make check payable to the Combined Federal Campaign Make check payable to the Combined Federal Campaign DESIGNATED GIFT: To designate one or more charities or federated groups, fill in the CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to the organizations via this pledge card. Date of Contribution: charity code(s) and dollar amounts above. Undesignated gifts are distributed among all organizations in proportion to their pledges. PAYROLL DEDUCTION AUTHORIZATION I hereby authorize any agency of the United States Government by which I may be employed during 2015 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2015 starting with the first pay period that begins in January and ending with the last pay period that begins in December, and to pay the amounts so deducted to the Combined Federal Campaign shown above. I understand that this authorization may be revoked by me in writing at any time before it expires. COPY #3 CONTRIBUTOR KEEP FOR PERSONAL TAX RECORDS In addition to my contact information, I authorize the CFC to release the amount of my pledge to the charity(ies) I designated above. SIGNATURE DATE OPM FORM 1654 REVISED MAY 2014

6 PRIVACY NOTICE Executive Order No authorizes the U.S. Office of Personnel Management to conduct fund raising activities and to establish procedures for collecting information related to such activities. Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security Number (SSN). This collected information will be disclosed to organizations maintaining the accounting of contributions and to your payroll office. Additional disclosure may be made to the Department of Treasury to make proper financial adjustments to a court or another agency when the government is party to a suit; and to the Internal Revenue Service and state and local taxing authorities regarding income tax returns. The furnishing of the SSN, along with other data requested, is voluntary. However, failure to furnish any of the requested information may result in errors or noncompliance with your request for a payroll deduction by your agency. If you are making a one-time, lump-sum gift and, therefore, not using the payroll deduction method of payment, you are not required to furnish your SSN.