Charity Ball Raffle – Payroll Deduction Charity Ball Raffle Payroll Deduction Please complete the form to authorize a payroll deduction. This is to authorize the Accounting/Payroll Department to deduct the Amount below (not to exceed $250) over the specified number of pay periods or by Thursday, November 12, 2021. (Deductions will begin next pay period.) I agree to have the listed Amount paid through payroll deduction. I also understand and agree that in the event my employment with CHC (and/or its affiliated corporations) is terminated before this obligation is satisfied, CHC (and/or its affiliated corporations) may deduct any or all amounts in excess of Federal Hourly Minimum Wage from my final paycheck as consideration for payment on this account and that I will remain responsible for entire balance which will be immediately due and owing by said date.Number of Raffle Tickets*Please enter a number from 1 to 5.Maximum of 5Raffle TicketsTotal Amount for Payroll Deduction $0.00 Number of Pay Periods*Please enter a number from 1 to 1.Number of Pay Periods*Please enter a number from 1 to 2.Employee Name* First Last Employee Number* Work Phone*Cell/Home Phone*Email* Entity* TMC Bowling Green TMC Scottsville TMC Franklin TMC Caverna Commonwealth Health Corporation Department* Options for Delivery of Receipt* Messenger service delivery to your department Mail Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please note that if you go on leave or terminate employment the amount due needs to be paid in full.NameThis field is for validation purposes and should be left unchanged.