You will receive a formal thank you letter prior to the payroll deductions start in September 2019. In the meantime, we want you to know we greatly appreciate your generosity.

Your gift is fully tax-deductible in accordance with current tax laws. No goods or services were provided in exchange for your gift. For tax purposes, please refer to your year-end pay summary on employee self-service. If you need help, please email one@healthpartners.com.

Amery Hospital & Clinic Foundation | 265 Griffin St. E. | Amery, WI 54001





Amery Hospital & Clinic Foundation - Payroll Deduction Donation Form
Your donations make good happen in our community. You positively impact the lives of patients, members and colleagues. Thank you for your support!

This form is for payroll deduction donations only. To give by Credit Card click the Give Now button when you click here.

Required fields are marked with *

Enter Your Contact Information
By entering my initials below, I authorized these donations to be taken out of my paycheck starting September 2019. I understand if I check sustaining donor that I will have the option to change or stop my contributions each year during the ONE campaign.
Organization-wide Support:
Title:
*State:
Apply my donation to (Please select at least one or more)Please enter the $ amount or hours you’d like to give to the following areas, then they will be added together for your total gift:Amery Hospital and Clinic support:
Apply my donation to (Please select at least one or more)

Please enter the $ amount or hours you’d like to give to the following areas, then they will be added together for your total gift:

Amery Hospital and Clinic support:
* How would you like to contribute:
* How would you like to contribute:
*Sign me up to be a sustaining donor! What does it mean to be a sustaining donor? Sustaining gifts are made via payroll deduction and will continue each pay period until you request a change. You will receive an annual opportunity to increase, decrease, discontinue or reallocate your gift. It’s that simple!
*Sign me up to be a sustaining donor! 
What does it mean to be a sustaining donor? Sustaining gifts are made via payroll deduction and will continue each pay period until you request a change. You will receive an annual opportunity to increase, decrease, discontinue or reallocate your gift. It’s that simple!
Initials
If you have any comments or notes regarding your gift, please write them here:
Education: HealthPartners Institute
Research: HealthPartners Institute
PTO Donation in hours
Enter the % of your PTO gift you would like for each area
 
 
 
 
 
 
 
 
 
 
 
 
Enter the $ amount of your Payroll donation you would like for each area
Apply my donation to (Please select at least one or more)Please enter the % amount you’d like to give to the following areas, then they will be added together for your total gift:Patient Care:Organization-wide Support:
 
 
 
 
 
 
 
 
 
 
 
 
If you have any comments or notes regarding your gift, please write them here: