2 for a list of PCFDs. Place the new PCFD in Box to the right. Place for a list of PCFDs. Place the new PCFD in Box to the right. Minimum deduction is 2.00 per month. 1 Amount Per Month (2 2 3 4 5 Amount Per Month (2 Organization Name (Required) Amount of Write-In TOTAL ALL Monthly Designations H. o This is a one-time check/cash contribution for the total amount of. (Please make check payable to: CSECC) K. o DECLINE I HAVE NO CURRENT DEDUCTIONS AND DO NOT WISH TO CONTRIBUTE AT THIS TIME (please initial) Page 1: PCFD Copy
2 for a list of PCFDs. Place the new PCFD in Box to the right. Place for a list of PCFDs. Place the new PCFD in Box to the right. Minimum deduction is 2.00 per month. 1 Amount Per Month (2 2 3 4 5 Amount Per Month (2 Organization Name (Required) Amount of Write-In TOTAL ALL Monthly Designations H. o This is a one-time check/cash contribution for the total amount of. (Please make check payable to: CSECC) K. o DECLINE I HAVE NO CURRENT DEDUCTIONS AND DO NOT WISH TO CONTRIBUTE AT THIS TIME (please initial) Page 2: Designated Organization / PCFD Copy
PCFD CODE NUMBERS (TO BE USED WHEN A FUND DRIVE CODE NUMBER IS NEEDED FOR BOX OR BOX ) PCFD ORGANIZATION AREA SERVED PCFD Code Arrowhead United Way Big Bear, Bloomington, Crestline, Colton, Devore, Grand Terrace, Highland, Lake Arrowhead, Loma Linda, Rialto, Running Springs, and San Bernardino 045 United Way of the Bay Area Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, and Solano Counties 022 United Way of Butte and Glenn Counties Butte and Glenn Counties 044 United Way California Capital Region Amador, El Dorado, Placer, Sacramento, and Yolo Counties 024 Central County United Way United Way of the Desert Desert Communities United Way Aguanga, Anza, Garner Valley, Gilman Hot Springs, Hemet, Homeland, Idyllwild, Lakeview, Menifee, Mountain Center, Nuevo, Pine Cove, Romoland, Sage, San Jacinto, Sun City, Winchester The Coachella Valley: Indio, Bermuda Dunes, Indian Wells, Cathedral City, Coachella, Desert Center, Desert Hot Springs, Sky Valley, Thousand Palms, Salton City, White Water, Pinyon, Indio Hills, Eagle Mountain, La Quinta, Mecca, North Shore, Palm Desert, Palm Springs, Rancho Mirage, Desert Shore, Oasis and Thermal. Adelanto, Apple Valley, Baldy Mesa, El Mirage, Helendale, Hesperia, Lucerne Valley, Oak Hills, Oro Grande, Phelan, Pinon Hills, Summit Valley, Victorville, and Wrightwood 011 04 09 United Way of the East Valley Redlands, Mentone, Highland, Loma Linda, Yucaipa, Calimesa, Forest Falls, Oak Glen 05 United Way of Fresno County Fresno, Madera and Mariposa Counties 028 United Way of Greater Los Angeles Los Angeles County excluding Diamond Bar, Pomona, San Dimas, and Walnut 004 United Way of Humboldt County Humboldt and Del Norte Counties 04 United Way of Imperial County Imperial County 002 Inland Empire United Way United Way of the Inland Valleys Eastern Los Angeles and Western San Bernardino Counties including: Claremont, Diamond Bar, La Verne, Pomona, San Dimas, Walnut, Chino, Chino Hills, Fontana, Montclair, Ontario, Lytle Creek, Upland, Rancho Cucamonga, Mt. Baldy Banning, Beaumont, Cabazon, Cherry Valley, Glen Avon, Jurupa, Mira Loma, Pedley, Rubidoux, Lade Elsinore, Canyon Lake, Wildmar, March Field, Moreno Valley, Perris, Temecula, Murrieta, Riverside, Corona, Norco, El Cerrito, Home Gardens, Lake Matthews and surrounding county land. 059 019 United Way of Kern County Kern, Inyo, and Mono Counties 01 Kings United Way Kings County 014 United Way of Merced County Merced County 05 United Way of Monterey County Monterey County 03 Nevada County United Way Nevada County 013 United Way of Northern California Lassen, Intermountain area, Shasta, Siskiyou, Tehama, Trinity, Modoc, and Plumas Counties 040 Orange County United Way Orange County 005 Palo Verde United Way Palo Verde Valley, Blythe in Eastern Riverside County 003 United Way of San Diego County San Diego County 032 United Way of San Joaquin County San Joaquin County 023 United Way of San Luis Obispo County San Luis Obispo County 039 United Way Silicon Valley Santa Clara and Santa Cruz Counties 029 United Way of Sonoma-Mendocino-Lake Lake, Mendocino, and Sonoma Counties 03 United Way of Stanislaus Area Stanislaus, Tuolumne, and Calaveras Counties 012 United Way of Tulare County Tulare County 081 United Way of Ventura County Ventura County 010 Yuba-Sutter United Way Yuba and Sutter Counties 05
2 for a list of PCFDs. Place the new PCFD in Box to the right. Place for a list of PCFDs. Place the new PCFD in Box to the right. Minimum deduction is 2.00 per month. 1 Amount Per Month (2 2 3 4 5 Amount Per Month (2 Organization Name (Required) Amount of Write-In TOTAL ALL Monthly Designations H. o This is a one-time check/cash contribution for the total amount of. (Please make check payable to: CSECC) K. o DECLINE I HAVE NO CURRENT DEDUCTIONS AND DO NOT WISH TO CONTRIBUTE AT THIS TIME (please initial) Page 3: Donor s Copy
CALIFORNIA STATE EMPLOYEES CHARITABLE CAMPAIGN PAYROLL DEDUCTION INSTRUCTIONS PLEASE COMPLETE AND RETURN THIS PLEDGE FORM TO YOUR STATE EMPLOYEE CAMPAIGN REPRESENTATIVE. Box 1. Social Security Number: Please complete this section with your Social Security Number. NOTE: The State Controller s Office requires your Social Security Number for all payroll deduction actions. Box 2. Employee Name: This section should be completed by the Controller s Office. If blank, please complete. Box 3. Agency: This section should be completed by the Controller s Office. The Agency code is the number used by the Controller for your agency/department. Box 4. Unit:This section should be completed by the Controller s Office. The Unit code is the number used by the Controller for your specific unit within the agency/ department. Box 5. Current Fund Drive Code: This section should be completed by the Controller s Office. The Fund Drive code is a geographic indicator used by the Controller for the agency, known as the Principal Combined Fund Drive (PCFD) agency, responsible for overseeing the Campaign in a particular region. Box. New Fund Drive Code: If you are a new donor you must specify a PCFD to manage your donation. Select a PCFD from the back of page 2 and write it in this box. See Step A under HOW TO MAKE A DEDUCTION for more information. Box. New Fund Drive Code: If you would like to choose a new PCFD to manage your donation, other than the one currently listed in Box 5, select the new PCFD from the back of page 2 and write it in this box. See Step D under HOW TO MAKE A DEDUCTION for more information. HOW TO MAKE A DEDUCTION Item A. NEW Payroll Deduction: This section is for new payroll deduction participants only. You must specify a PCFD to manage your donation. Select a three digit PCFD from the back of page 2 and write it in Box. The dollar amount placed to the right is the amount per month of the payroll deduction. Item B. CHANGE My Existing Deduction Amount: This section is for previous payroll deduction participants only. The dollar amount placed to the right is the TOTAL dollar amount of the payroll deduction. Checking this box will cancel previous designations please see Special Note under HOW TO MAKE A Item C. DELETE I No Longer Wish to Contribute: If you no longer wish to contribute, you MUST check this box in order for the State Controller s Office to discontinue your monthly deduction. Item D. CHANGE My Principal Combined Fund Drive (PCFD): This section is for current payroll deduction participants only who wish to change the PCFD which manages their donation. Your current PCFD is listed in Box 5 at the top of the pledge form. To choose a new PCFD to manage your donation select the new PCFD from the back of page 2 and write it in Box. The dollar amount placed to the right is the amount per month of the payroll deduction. Checking this box will cancel previous designations please see Special Note under Item E. CONTINUE My Existing Deduction: Your deductions will continue from year to year. Checking this box verifies the Government Code has If you choose to have the same amount deducted from your payroll, please mark this box. You may change your designations by filling out section G. If you do not fill out section G, your designations from the previous year will remain as directed. Item F. Signature and Date: Your signature and date authorize the State Controller s Office to begin/change/delete payroll deductions in the amount provided. HOW TO MAKE A DESIGNATION SPECIAL NOTE regarding designations An employee has the right to designate all or part of their contribution to a 501(c)(3) non-profit organization(s) of their choice. Any undesignated portion will be distributed to charitable organizations by the Also note that any changes to Items B or D will cancel all previous designations and new designations would be necessary. Item G. I wish to make the following designations: If you choose to designate your contributions to a 501(c)(3) non-profit organization(s), please write the name of the organization and its code number from your Donor Resource Guide, along with the amount per month that you wish this organization to receive. (2.00 minimum per organization). Write-In organization information: If you choose to donate to a 501(c)(3) non-profit organization that is not listed in your Donor Resource Guide, write-in that organization s complete name, address and phone number. Because Write-Ins are not approved by the Board, they are not included in the Donor Resource Guides. Item H. One-Time Contribution: If you choose to donate a one-time contribution, make check payable to CSECC in the amount you wish to donate. You may designate your gift by using Section G above. Item I. Acknowledgement: If you wish to receive an acknowledgement from the PCFD, please provide your complete mailing address below. If you move, the PCFD must be informed of your new address to insure your receipt of the acknowledgement. Your designated organization(s) will also receive your address. NOTE: This must be provided on an annual basis. Item J. Signature and Date: Your signature and date authorize the PCFD agency to distribute your contributions. Item K. Decline Not Interested at this Time: Please check the box and sign your initials on the line provided. Your initials ensure staff that you have been provided the opportunity to participate in the Campaign, as required by State statutes. ADDITIONAL INFORMATION A designation continues from year to year unless participant changes their donation amount or indicates otherwise in Section G. Only 501(c)(3) non-profit organizations are qualified to receive designations. The PCFD will make a reasonable attempt to contact the donor for all designations to unqualified organizations. If the PCFD is unable to contact the donor, the donation will be distributed to charitable organizations by the The State Controller s Office will not receive the designation portion of this form. The PCFD organization will deduct its expenses (approved by the Victim Compensation and Government Claims Board) before a designation payment is distributed to an organization.