The Neuropathy Association, Inc.: Payroll Deduction Form

Many companies, large and small, permit their employees to make charitable
contributions to qualified non profit organization through regular payroll deductions.
Individual company policies and payroll procedures vary, so you are encouraged to
call the Payroll Office of your employer to determine if this option is available to you.

The following is a sample form:

Payroll Deduction Authorization: I authorize Payroll Office to deduct the following amount from
my wages to fulfill my pledge to The Neuropathy Association, a qualified 501c3 nonprofit organization.

$__________ to be deducted ___ one time __ monthly __weekly. Annual total: $ ______

Deductions to start ____/____/____ (m/d/y) and continue until instructed to end

Employee signature: ____________________________

Employee number: ____________________________
I reserve the right to alter this commitment.

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