Give a High Five for Kids

Employee payroll deduction form

Fields marked with are required.

First Name

Last Name

Address

City

State

Zip Code

Cell Phone

Department

Employee ID

As a UPMC Hamot Employee, I am paid (please select):

Biweekly (26 pays per year)

Monthly (12 pays per year)

Deduction amount per pay

$5.00

$10.00

$20.00

Other

Please list other amount here

Authorization

By submitting this form, I understand that I am pledging philanthropic support to Hamot Health Foundation. I authorize the necessary amount to be automatically deducted from my pay each pay period to fulfill my total pledge in the amount of time selected above.