Contribution sign-up form
Name: ___________________________________
Employee ID: ______________________________
Dept: ____________________________________
1% Contribution per paycheck*: ______________
Combined Municipal Campaign 2014
Contribution Type:
Per paycheck (24x)
Attach Cash, Check or
Money Order (M.O.)
Check/M.O. made out to agency
Agency Code
One time deduction
Cash
Check/M.O. made out to CMC
Agency Name
Amount
$
$
$
$
$
Per paycheck
Check / M.O.
$
Per paycheck total for 2012 (multiply by 24)
Total
$
One time deduction
Cash
I would like to be an Above & Beyond Club contributor by giving 1% or more of my pay
Yes
No
I would like an acknowledgement from the agency that may be used as a tax receipt
Yes
No
If yes, please provide an e-mail address
@
Employee Signature: ______________________________________ Date: _____________________
By signing this form, I acknowledge I have read and understand the policies and procedures as stated in the CMC Tribute.
*How to calculate my 1%
In this example, the employee would donate $10.83
from each paycheck to be in the Above & Beyond Club.
Biweekly Total Gross Pay = ___________
$ 26,000
multiply by 26 = ___________
divide by 24 = ___________
Scan to visit
www.houstoncmc.org
$ 1,000
Example Biweekly Total Gross Pay = ___________
multiply by 26 = ___________
$ 1083.33
divide by 24 = ___________
divide by 100 = ___________
divide by 100 = ___________
$ 10.83
The CMC admin. fee is 4%.
Make a copy of this form for your records.