Oconee Memorial Hospital Foundation Employee Payroll Deduction Authorization Form

Please complete this form to authorize payroll deductions to support Oconee Memorial Hospital Foundation (Nonprofit Tax ID # 56-2141740). Deductions will begin October 1, 2023.

For more information or to request a different form of payment, contact Cortni Nations at Oconee Memorial Hospital Foundation at 864-885-7912 or Cortni.nations@prismahealth.org

Your information below will only be shared with Oconee Memorial Hospital Foundation and Prisma Health Payroll. Donor information is confidential and not shared with outside parties.

Oconee Memorial Hospital Payroll Deduction Authorization Form

Personal Information

Name

First

Last

Address *

Address

Street Address

Street Address 2

City

State/Province

Zip/Postal

Email Address *

Phone Number *

Work Information

Employee Number *

Department Name *

Hospital/Dept Number

Donation Information

My Charitable Gift to OMH Foundation supports: My Charitable Gift to OMH Foundation supports:

Donation amount per period

Would you like your donation to be a one time deduction or a full year of deductions?

One time payroll deduction

Full year payroll deduction

Signature

My donation totals $1,000+. I will be recognized as a “Major Donor” by OMH Foundation, giving my permission to be recognized in special publications and invited to attend the Foundation’s Major Donor Appreciation Event.

My donation totals a minimum of $26 (or $1 per pay period). I would like to be listed on the Employee Recognition Display located in the OMH Connector.

Enter your full name to sign this form *

Date *

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