AVH Foundation Employee Payroll Deduction Form

AVH Foundation Employee Payroll Deduction Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
AVH Extension
Email*
example@example.com
How much would you like to donate?*

$38.46 per paycheck ($1000 annual donation)$25 per paycheck ($650 annual donation)$15 per paycheck ($390 annual donation)$10 per paycheck ($260 annual donation)$5 per paycheck ($130 annual donation)$1 per paycheck ($26 annual donation)One-time donation:Other amount (per paycheck):
Amount:*
I authorize a payroll deduction to commence on my next paycheck which shall continue until I notify the Foundation office or payroll department of any change.

Gifts will be accepted as unrestricted donations, giving the Foundation the most flexibility to direct the donations to priority programs and projects, unless specified below:
Direct my gift to:

The Fund for Aspen Valley HospitalAVH Employee Emergency Financial Assistance Plan
Signature*
Date*

MonthDayYear
Date
Thank you for your generous support to provide extraordinary healthcare in an environment of excellence, compassion, and trust.

The Aspen Valley Hospital Foundation is a tax-exempt nonprofit organization under section 501(c)(3) of Internal Revenue Code. Gifts may be tax-deductible to the extent permitted by law.
0401 Castle Creek Road | Aspen, CO 81611 | Ph: 970.544.1302 | Fax: 970.544.1164 | avhf@aspenhospital.org
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