2013 UCSF Combined Charities Campaign
  • Select a specific federation or one of its affiliated agencies to support from the links below. If a tax-exempt organization or program is not listed among the options, you should use the "Donor Choice Plan" to fill in the complete agency name, address and dollar amount of your contribution to that group. Click here if you would rather print out a campaign brochure and donation form.
  • Enter the payment type of your gift (s): payroll deduction or check.
  • Enter the amount of your gift (s) per pay period.
  • Select the number of pay periods: 1-one time, 12-monthly, 24-bi-weekly
  • Community Health Charities of California and all federations charge an administration fee for each pledge. For more information you can call CHCC at (925) 849-4434 or email at Kscull@healthcharities.org.
  • Campaign deadline for donations/pledges is Sunday, December 14, 2014.

    DONOR INFORMATION


* indicates required field
DONOR INFORMATION
Name: *
     
Department Name: *  
Employee Number: *  
Work Phone: *  
County: *
Email Address: *  
DONATION INFORMATION
Federations:








Charity:
Enter the Recipient Code from the list into the Donation fields below along with a Donation Amount.  The Total Donation field must match the total amount of the individual donations entered.
Payment Type: *
If you are paying via Payroll Deduction, the following amounts are per pay period.
 
Recipient Code     Donation Amount
Donation 1:  :      $
Donation 2:  :      $
Donation 3:  :      $
Donation 4:  :      $
Donation 5:  :      $
Donation 6:  :      $
Donation 7:  :      $
Donation 8:  :      $
Donation 9:  :      $
Donation 10:  :      $
Donation 11:  :      $
Donation 12:  :      $
Please write in only valid 501(C)3 nonprofit organizations. You may check the status of the charity of your choice by visiting www.guidestar.org or www.charitynavigator.org
For donor choice charities (nonmember charities) the processing fee is 15%
Donor Choice Write-in #1:
The following fields are only required if you are selecting a write-in charity.
Write-in Amount: * $ 
Write-in Charity Name: *  
Address: *

 
If you wish to support a UCSF department or program, please visit the UCSF giving page, click here.
City: *  
State: *
Zip: *  
Phone:  
Donor Choice Write-in #2:
The following fields are only required if you are selecting a write-in charity #2.
Write-in Amount: * $ 
Write-in Charity Name: *  
Address: *

 
If you wish to support a UCSF department or program, please visit the UCSF giving page, click here.
City: *  
State: *
Zip: *  
Phone:  
Donor Choice Write-in #3:
The following fields are only required if you are selecting a write-in charity #3.
Write-in Amount: * $ 
Write-in Charity Name: *  
Address: *

 
If you wish to support a UCSF department or program, please visit the UCSF giving page, click here.
City: *  
State: *
Zip: *  
Phone:  
Total Donation: * $ 

If you are paying via Payroll Deduction, this amount is the total donation per pay period.
PAYMENT INFORMATION
The following fields are only required if you are paying by payroll deduction.
Pay Periods: *
Total Annual Donation: * $ 

* Employees paid bi-weekly will have the monthly deduction amount divided between two bi-weekly paychecks. No deduction will be taken from a D3 (deduction holiday) paycheck.

Payroll Deduction: Please read the following information. UCSF employees must approve payroll deduction by checking the authorization box below. *required

This agreement shall remain in effect until revoked by me, allowing up to 30 days' time to change the payroll records in order to make effective this assignment or revocation thereof. Upon termination of employment with the University, this authorization will no longer be in effect. Payroll deductions, including those legally required and those authorized by an employee are assigned priorities. In the event there are insufficient earnings to cover all required and authorized deductions, it is understood that deductions will be taken in the order assigned by the University and no adjustment will be made in the subsequent pay period for amounts not deducted by reason of insufficient earnings. Deduction forms will be processed immediately upon receipt by UCSF Payroll Services; however, due to processing requirements and deadlines, this payroll deduction may take up to two (2) pay periods to begin.

* authorize payroll deduction for my donation (s).

ACKNOWLEDGE GIFT
Acknowledge Gift:
The following fields are only required if you have checked the "Acknowledge Gift" box.
Address: *  
   
City: *  
State: *
Zip: *  
Phone:  
NOTES
You can enter additional comments or suggestions here.
Before submitting, please print out this form as your tax receipt. If you selected payroll deduction, refer to your W2 or UCSF earnings statement to verify your gifts.

If you are donating by check, please make your check out to Community Health Charities of California, print this form, attach your check and mail to: Community Health Charities of California 1331 Garden Highway Suite 100 Sacramento CA 95833.