927 Churchill St. W., Stillwater, MN 55082 | 651-430-4556 | paul.l.erickson@lakeview.org


Lakeview Health Foundation Payroll Deduction Donation Form

Your donation makes good happen in our community. You positively impact the lives of patients, members and colleagues. Thank you for your support!

Make your gift by April 30 and your contribution will qualify for the HealthPartners match.

This form is for payroll deduction donations only. Please visit the Lakeview Health Foundation page if you wish to make a donation by credit card.

Thank you for supporting the ONE Employee Giving Campaign with your contribution. Your generosity truly makes an impact in the lives of those in our community. When 26,000 people each offer a little help, amazing change is possible.

A letter will be sent to acknowledge your donation. Your gift is tax deductible to the extent provided by law, and Lakeview Health has not provided any goods or services in exchange for your gift.

By entering my initials below, I authorize these donations to be taken out of my paycheck. I understand that if I check sustaining donor that I will have the option to change or stop my contributions each year during the ONE Campaign.

Choose the areas you want to support

Patient Care and Programs at Lakeview:
* Payment method - If you wish to make donations by credit card, please click here.
Organization-wide support
Title:
*State:
Apply my dollar ($) donations to (please select at least one designation for your gift):
Apply my dollar ($) donations to (please select at least one designation for your gift):
HOPE Chest:
 
*How I would like to contribute (please choose one):
*How I would like to contribute (please choose one):
Payroll deduction: Split my donation across 24 pay periods beginning September 2017
What year would you like the deductions to begin?
you may choose to have your gift split evenly through pay periods for one year beginning.
What year would you like the deductions to begin?
Sign me up to be a sustaining donor! Sustaining gifts will continue until you request a change. You will have an annual opportunity to increase, decrease, discontinue or reallocate your gift.
Initials
If you have any comments or notes regarding your gift, please write them here:
Park Nicollet Foundation
Education: HealthPartners Institute
*Would you like to be a sustaining donor? (As a Sustaining donor, your charitable contribution, via 24 payroll deductions, will continue until you request a change. You will receive an annual opportunity to increase, decrease, discontinue or reallocate your gift. It's that simple! Thank you!)
*Would you like to be a sustaining donor? (As a Sustaining donor, your charitable contribution, via 24 payroll deductions, will continue until you request a change. You will receive an annual opportunity to increase, decrease, discontinue or reallocate your gift. It's that simple! Thank you!)