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SSF: Payroll deduction example

Payroll deducation example.jpg

Funnel Cake Manufacturer PAC

[Check box] I, ______________________, understand that my contribution to the Funnel Cake Manufacturer PAC is voluntary. The purpose of the Funnel Cake Manufacturer PAC is to raise and spend funds to benefit activities and political candidates on the federal level that support the interests of the organization.

I authorize Funnel Cake Manufacturer PAC to deduct the designated amount per pay period from my paycheck. It is my understanding that this authorization will remain in effect until I revoke that authorization in writing. I am aware that I can contribute up to $5,000 to the Funnel Cake Manufacturer PAC per year.

I am aware that there is no expectation that I participate in the Funnel Cake Manufacturer PAC payroll deduction fundraising efforts. It has been made clear to me that I may refuse to contribute without reprisal.

Recommended Amounts Per Pay Period

Executive/Administrative Level 1: $20
Executive/Administrative Level 2: $15
Executive/Administrative Level 3: $10

The recommended contribution amounts listed above are merely suggested amounts. Employees may choose to give more or less than stated. I understand that I will not be favored or disadvantaged by reason of the amount of my contribution or my decision not to contribute.

I elect to contribute $______________________ per pay period.

[Check box] I, _____________________________, choose to make a one-time contribution of $___________ to the Funnel Cake Manufacturer PAC.

[Check box] I, _____________________________, elect not to make a contribution at this time.

NAME: ______________________________________________
ADDRESS: ____________________________________________
OCCUPATION: ________________________________________
SIGNATURE: __________________________________________
DATE: _______________________________________________

Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions exceed $200 in a calendar year.