Central & Northern New Mexico
Combined Federal Campaign Online Pledge Form
CFC Campaign No. 0606
City/State Code: 35 0030
1224 Pennsylvania NE, Suite A, Albuquerque, NM 87110 Please complete, print and submit this form to make your 2011 campaign
pledge online.
IMPORTANT NOTES: * You must print 2 copies of this form in addition
to your electronic submission.Copy 1 is for your payroll
department and must include your social security number and signature.
Copy 2 is for your records. Thank you. * Required fields are in
RED UPPERCASE.
Information About You
FIRST NAME:
Middle Initial:
LAST NAME:
Social Security Number / Employee
ID
(Write On Printout if Choosing Payroll Deduction)
__ __ __ - __ __ - __ __ __ __
TYPE OF
EMPLOYEE:
FEDERAL AGENCY AND
OFFICE:
WORK ADDRESS:
WORK CITY, STATE, ZIP:
WORK PHONE (Including Area Code):
Information About Your
Contribution Fill in the blanks below showing the amount of
your payroll allotment, cash or check contribution, then use the
"Calculate" button to determine and verify the total of your annual
contribution. NOTE: CFC organizations do not provide goods or services in
whole or partial consideration for any contributions made to the
organization via this pledge card.
Allotment Source (if Military,
branch of service: )
Standard Amount per Payroll
Period:
Other ADDITIONAL Amount
(cash/check payable to CFC):
$
Check #
TOTAL CONTRIBUTION:
$
DATE OF CONTRIBUTION:
Designated Gifts To designate one or more charities or federated
groups that appear on the list provided (click here to open a new
window containing the current list), fill the charity or federation code(s) and dollar amount(s) below, then
use the
"Verify" button to validate and check the total of your
designations. Use the New FIVE-DIGIT CFC Codes Only. Undesignated gifts are distributed among all
organizations in proportion to their pledges.
Charity/Group Code
(FIVE DIGITS):
Annual Amount:
Undesignated Amount (recalculate
with "Verify Designations" button):
$
Designation 1:
$
Designation 2:
$
Designation 3:
$
Designation 4:
$
Designation 5:
$
Recognition
Options
INFORMATION RELEASE (OPTIONAL) Any information you enter below will be released, along with your name, to the
charity(ies) to which you made a pledge. Do not enter your work address or email.
Home Address
Personal Email Address
In addition to my contact information, I authorize the CFC to release the amount of
my pledge to the charity(ies) I designated above.
Payroll Deduction Authorization (Write On Printed Form) I hereby authorize any agency of the United States Government by which I may be
employed during 2012 to deduct the amount(s) shown above from my pay each pay
period during the calendar year 2012 starting with the first pay period that begins in
January and ending with the last pay period that begins in December, and to pay the
amounts so deducted to the Combined Federal Campaign shown above. I understand
that this authorization may be revoked by me in writing at any time before it expires.