1. 2011 Directed Giving Alliance of Olmsted County
(Local Independent Charities of Minnesota)
SEE REVERSE FOR INSTRUCTIONS !
Last Name First Name M.I. Department Name
Employer Work Phone
TOTAL: $ (per pay period) x pay periods* = $ annually
Check Amount Per
3 Code Agency Name Pay Period
73789 Give to All $
Donations will be distributed among all the listed charities
52351 American Red Cross - Southeast Minnesota Chapter $
32015 Arc Southeastern Minnesota $
24035 Bear Creek Services $
03211 Bolder Options Rochester $
39576 Boy Scouts of America, Gamehaven Council $
03212 Diversity Council $
31199 Dorothy Day Hospitality House $
55626 Gift of Life, Inc. $
29988 Paws and Claws Humane Society $
30220 Rochester Arts Council $
52572 Rochester Better Chance Foundation $
03213 Rochester Neighborhood Resource Center $
03214 Rochester Public School Foundation $
97540 RT Autism Awareness Foundation, Inc. $
03215 Samaritan Bethany Foundation $
33482 Seasons Hospice $
68573 Senior Citizens Services, Inc. $
52398 Southeastern Minnesota Youth Orchestra, Inc. (SEMYO) $
63018 Special Olympics Minnesota Inc. $
88062 Wing House Corporation $
55641 Women’s Shelter Inc. $
TOTAL:
(per pay period) $
If you would like to be acknowledged, please complete the following information.
Email or street address City Zip
Work Phone Number
ORIGINAL - WHITE FEDERATION - YELLOW DONOR – PINK RETAIN PINk COPY OF THIS FORM FOR TAx PuRPOSES
No goods or services are provided in consideration of the contribution(s) pledged on this form.

2. Pledge Form Guidelines
1) Fill out your name, your Employer/Company Name, your employee ID/SS# (for payroll deduction purposes), and your work
telephone number. This information will remain confidential and will only be used in processing your donation. It will not be
provided to the charities.
2) Indicate which charity(ies) you wish to give to by checking the box next to their name on the left and filling in the amount PER
PAY PERIOD in the column to the right.
3) Once you have completed the portion of the form indicating which organizations you wish to give to and how much you would
like to give to each per pay period, complete the bolded portion toward the top of the form. Indicate the total amount you wish
to be deducted from your paycheck (this should match the total at the bottom of the right column), how many pay periods you
have a year*, and the total annual amount to be deducted (annual amount is determined by multiplying contribution per pay
period by the number of pay periods your company has each year).
* PLEASE NOTE: NuMBER OF PAY PERIODS IS DETERMINED BY YOuR EMPLOYER. If you are unsure
how many pay periods you have each year, please contact your payroll administrator.
4) To receive written acknowledgement for your gift, complete the bottom portion of the form with a legible, valid email or mailing address.