FY25 Employee Giving Campaign

Employee Giving Campaign

Payroll Deduction Form
Employee Identification Number*
E#
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Department*
Champion
Enter the name of the team member who inspired your participation.
Do you primarily work on the main hospital campus?

YesNo
Champion
Please deduct the below amount from my paycheck*

Only Once (this is a one-time gift)Per paycheck (this is a recurring gift)Power of $5 Club (this is a recurring gift of $5)Power of $10 Club (this is a recurring gift of $10)
Gift Amount*
Please designate my gift to:*
Other Fund Designation:
This gift is anonymous:

Yes, please do not include my name in any recognition listings.
I authorize Jupiter Medical Center to deduct the amount indicated, on an after taxes basis, from my pay and send it to the Jupiter Medical Center Foundation. Recurring donations will continue until donor contacts the Foundation to cancel.
Signature*
Date*

MonthDayYear
Date
I want an annual tax statement mailed at the end of the year.

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The care our team members provide often inspires gifts to our hospital. If you have a reason for this gift today and would like to share, we would love to learn more about your generosity.

Yes, I'd like to share what inspired my gift.
I made a gift to the Better Together campaign because:
Jupiter Medical Center Foundation is a 501(c)3 not-for-profit organization as designated by the Internal Revenue Service.Contributions are tax deductible to the extent provided by state and federal law. Our Federal Tax Identification Number is 65-0132406

A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE 1-800-HELP-FLA OR ONLINE AT FDACS.gov.
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