Employee Payroll Deduction Form

If you are a UPMC Hamot employee and would like to support Hamot Health Foundation through payroll deduction, please complete the form below.

Fields marked with are required.

First Name

Last Name

Address

City

State

Zip Code

Cell Phone

Email

Department

Employee ID

As a UPMC Hamot Employee, I am paid (please select):

Deduction amount per pay

$3.00

$5.00

$10.00

$20.00

Other

Please list other amount here

Please direct my deduction to:

Employee Career Development

United Charities Fund

Greatest Needs

Other area I would like to support

Authorization

By submitting this form, I understand that I am pledging philanthropic support to Hamot Health Foundation. I authorize the necessary amount to be automatically deducted from my pay each pay period to fulfill my total pledge in the amount of time selected above.

Employee Payroll Deduction Form

If you are a UPMC Hamot employee and would like to support Hamot Health Foundation through payroll deduction, please complete the form below.

Authorization

For Corporators

For Volunteers