Join your fellow federal workers and make it possible by donating to your chosen charities through CFC. There are just two simple steps:

1) CHOOSEBrowse the 2015 Catalog of Caring or visit www.cfcnca.org to find causes that are meaningful to you. Don’t forget to note the five-digit codes for the charities you select.

2) DONATEGive online at www.cfcnca.org. You can donate through payroll deduction, which is one of the best ways to contribute to your favorite charities, or you can donate using a credit/debit card or eCheck.

OR

Complete this pledge form, then give it to your Keyworker to process your pledge. Please keep the blue copy for your records.SAMPLE

$75 per pay period helps a community in Africa enjoy safe drinking water.

$50 per pay period protects a crucial wildlife habitat for an endangered species.

$35 per pay period provides an injured veteran with physical rehabilitation and

emotional support.

$25 per pay period supports clinical research to cure cancer, diabetes, autism,

and other diseases.

$20 per pay period trains volunteers to advocate for abused and neglected

children.

$12 per pay period shelters and feeds a family devastated by a tornado.

$6 per pay period delivers nutritious meals to a senior citizen with dementia.

CFC honors the extraordinary generosity of federal workers who contribute 1% or 2% of their gross pay with the Eagle Award (1%) and Double Eagle Award (2%).

If you have earned an Eagle or Double Eagle Award, please request your Pin from your Keyworker.

Prefer to pledge online?

Visit www.cfcnca.org to quickly and easily donate by payroll deduction, credit/debit card, or eCheck.

If you don’t know your reporting unit number, visit www.cfcnca.org to access the Reporting Unit Lookup Tool or ask your Keyworker.

For help making your pledge, visit www.cfcnca.org or call 202-465-7230.

Payroll deduction makes it easy to give to the charities you care about.

Below are some common payroll pledge amounts per pay period:

Civilian:

$50 x $26 = $1,300

$25 x 26 = $650

$10 x 26 = $260

Military

$100 x 12 = $1,200

$50 x 12 = $600

$10 x 12 = $120

SAMPLE

COPY

#1

- PAY

ROLL

OFF

ICE

erutangiS

PAYROLL DEDUCTION AUTHORIZATION

enter below will be released, along with your name, to the charity(ies) to which you made a pledge. Do not enter your work address or email.

Home Address:

ALLOTMENT SOURCE

Reporting Unit Number

CFC e goods or services in whole considera any contribu e to the via this pledge card.

INFORMATION RELEASE (OPTIONAL)

(make check payable to the Combined Federal Campaign)

Work Phone Number

CITY/STATE CODE 110010

CFC Campaign Number 0990

SSN/Employee ID

Last Name

CASH/CHECK

Amount:Check Number:

MILITARY PAYROLLBranch of Service

PAY PERIOD AMOUNT INTERVAL TOTAL GIFT

$

$

x 12 months

x 26 pay periodsCIVILIAN PAYROLL

CONTRIBUTION: Fill in the blank showing the amount of your payroll allotment, cash or check contribu e in the total of your annual contribu the space provided.

Email

act informa amount of my pledge to thecharity(ies) I designated above.

Personal Email Address:

®

I hereby authorize any agency of the United States Government by which I may be employed during 2016 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2016 starting with the first pay period that begins in January and ending with the last pay period that begins in December, and to pay the amounts so deducted to the Combined Federal Campaign shown above. I understand that this authorization may be revoked by me in writing at any time before it expires.

PLE

ASE

USE

BA

LL P

OIN

T P

EN &

WR

ITE

FIR

MLY

$

$

$

ANNUAL AMOUNTCHARITY CODE

TOTAL:

$

$

$

$

$

$

DESIGNATED GIFT: Togroups, fill in the charity code(s) and dollar amounts above. Undesignated

buted amon

MIFirst Name

Combined Federal Campaign of the National Capital Areawww.cfcnca.org 2015 Campaign

etaD OPM Form 1654Revised June 2015

1000000

SAMPLENOTE: This form is for informational purposes ONLY.To donate, you must obtain a pledge form from your Keyworker.

erutangiS

PAYROLL DEDUCTION AUTHORIZATION

enter below will be released, along with your name, to the charity(ies) to which you made a pledge. Do not enter your work address or email.

Home Address:

ALLOTMENT SOURCE

Reporting Unit Number

CFC e goods or services in whole considera any contribu e to the via this pledge card.

INFORMATION RELEASE (OPTIONAL)

(make check payable to the Combined Federal Campaign)

Work Phone Number

CITY/STATE CODE 110010

CFC Campaign Number 0990

SSN/Employee ID

Last Name

CASH/CHECK

Amount:Check Number:

MILITARY PAYROLLBranch of Service

PAY PERIOD AMOUNT INTERVAL TOTAL GIFT

$

$

x 12 months

x 26 pay periodsCIVILIAN PAYROLL

CONTRIBUTION: Fill in the blank showing the amount of your payroll allotment, cash or check contribu e in the total of your annual contribu the space provided.

Email

act informa amount of my pledge to thecharity(ies) I designated above.

Personal Email Address:

®

I hereby authorize any agency of the United States Government by which I may be employed during 2016 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2016 starting with the first pay period that begins in January and ending with the last pay period that begins in December, and to pay the amounts so deducted to the Combined Federal Campaign shown above. I understand that this authorization may be revoked by me in writing at any time before it expires.

PLE

ASE

USE

BA

LL P

OIN

T P

EN &

WR

ITE

FIR

MLY

$

$

$

ANNUAL AMOUNTCHARITY CODE

TOTAL:

$

$

$

$

$

$

DESIGNATED GIFT: Togroups, fill in the charity code(s) and dollar amounts above. Undesignated

buted amon

MIFirst Name

Combined Federal Campaign of the National Capital Areawww.cfcnca.org 2015 Campaign

etaD OPM Form 1654Revised June 2015

COPY

#2

- TO

TH

E CE

NTR

AL

RECE

IPT

POIN

T

1000000

SAMPLENOTE: This form is for informational purposes ONLY.To donate, you must obtain a pledge form from your Keyworker.

COPY

#3

- CO

NTR

IBU

TOR

- KEE

P FO

R YO

UR

PERS

ON

AL

TAX

RECO

RDS

erutangiS

PAYROLL DEDUCTION AUTHORIZATION

enter below will be released, along with your name, to the charity(ies) to which you made a pledge. Do not enter your work address or email.

Home Address:

ALLOTMENT SOURCE

Reporting Unit Number

CFC e goods or services in whole considera any contribu e to the via this pledge card.

INFORMATION RELEASE (OPTIONAL)

(make check payable to the Combined Federal Campaign)

Work Phone Number

CITY/STATE CODE 110010

CFC Campaign Number 0990

SSN/Employee ID

Last Name

CASH/CHECK

Amount:Check Number:

MILITARY PAYROLLBranch of Service

PAY PERIOD AMOUNT INTERVAL TOTAL GIFT

$

$

x 12 months

x 26 pay periodsCIVILIAN PAYROLL

CONTRIBUTION: Fill in the blank showing the amount of your payroll allotment, cash or check contribu e in the total of your annual contribu the space provided.

Email

act informa amount of my pledge to thecharity(ies) I designated above.

Personal Email Address:

®

I hereby authorize any agency of the United States Government by which I may be employed during 2016 to deduct the amount(s) shown above from my pay each pay period during the calendar year 2016 starting with the first pay period that begins in January and ending with the last pay period that begins in December, and to pay the amounts so deducted to the Combined Federal Campaign shown above. I understand that this authorization may be revoked by me in writing at any time before it expires.

PLE

ASE

USE

BA

LL P

OIN

T P

EN &

WR

ITE

FIR

MLY

$

$

$

ANNUAL AMOUNTCHARITY CODE

TOTAL:

$

$

$

$

$

$

DESIGNATED GIFT: Togroups, fill in the charity code(s) and dollar amounts above. Undesignated

buted amon

MIFirst Name

Combined Federal Campaign of the National Capital Areawww.cfcnca.org 2015 Campaign

etaD OPM Form 1654Revised June 2015

1000000

SAMPLENOTE: This form is for informational purposes ONLY.To donate, you must obtain a pledge form from your Keyworker.

Privacy Act NoticeExecutive Order No. 12353 authorizes the U.S. Office of Personnel Management to conduct fund raising activities and to establish procedures for collecting information related to such activities.

Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security Number (SSN). This collected information will be disclosed to organizations maintaining the accounting of contributions and to your payroll office.

Additional disclosure may be made to the Department of Treasury to make proper financial adjustments to a court or another agency when the government is party to a suit; and to the Internal Revenue Service and state and local taxing authorities regarding income tax returns.

The furnishing of the SSN, along with other data requested, is voluntary. However, failure to furnish any of the requested information may result in errors or noncompliance with your request for a payroll deduction by your agency.

If you are making a one-time, lump-sum gift and, therefore, not using the payroll deduction method of payment, you are not required to furnish your SSN.

SAMPLE