Employee Payroll Deduction Form

Select one of the following: *

First Name *

Middle Initial

Last Name *

Residence Address *

Physical Address required - No P.O. Boxes

City *

State *

Zip Code *

Mailing Address

If different from residence address

City

If different from residence address

State

If different from residence address

Zip Code

If different from residence address

Email *

Daytime Phone *

Location Where You Work *

Begin Contributions on the Date: *

Authorization *

I authorize my employer to withhold the following charitable donation from my wages each pay period:

Electronic Tax Forms

I authorize ExplorUS Cares to provide me with electronic copies of tax forms and any other forms as required by law. I agree to opt out of receiving paper copies of any and all documentation. I would like to receive my forms at the following email address:

Email

Charitable Donation Options (Post Tax) *

When would you like your contribution change to occur?

Other Amount (If Selected)

I wish to discontinue my contributions to ExplorUS Cares

Date to discontinue contributions