Middle Park Medical Foundation Gift Deduction Authorization

Middle Park Medical Foundation Gift Deduction Authorization
Name

First NameLast Name
Email
example@example.com
I authorize Middle Park Health to deduct $Dollar Amount* per pay period from my paycheck to make a tax deductible gift to Middle Park Medical Foundation.
I request my tax deductible gift be used for (select all that apply):
Thank you for your recurring gift to Middle Park Medical Foundation, every little bit goes a long way!
Signature
Should be Empty: