Bluemont Cares Payroll Deduction Authorization Form

Bluemont Cares Payroll Deduction Authorization Form
The Bluemont Cares Fund (BCF) is a program initiated by the Bluemont Group in 2024 to support team members facing significant and immediate financial hardships due to unforeseen circumstances such as illness, injury, natural disasters, or other catastrophic events. Funded by contributions from team members and fundraising activities, BCF offers financial assistance of up to $1,000 per year to those in need.
Today's Date*

MonthDayYear
Date
Legal First and Last Name*

First NameLast Name
$1$2$5$10$20Other
Last 4 Digits of Social Security Number:*
Acknowledgment
I authorize the above reoccuring deduction from my gross earnings. I understand this deduction is not tax deductible and I will be responsible for paying all taxes owed. This deduction will be pooled with other funds exclusively to further the goal of helping team members in times of significant and immediate need. You need not contribute to the Fund to request assistance.
Yes
Should be Empty:

Acknowledgment