SEBA Charity Fund Deduction
Member Name
*
First Name
Last Name
Employee ID #
*
Personal Email
*
example@example.com
I wish to make the following voluntary deduction contribution (per pay period) to the SEBA Charity Fund, a 501(c)3 organization, tax ID #77-0606318. Contributions made to this fund are tax deductible.
$2.50
$5
$10
$20
Other (Please fill in amount below)
I authorize the Sheriff’s Employees’ Benefit Association (SEBA) to deduct the amount indicated above from each payroll warrant for pay period beginning:
Select Pay Period Here
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: