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2016 Connecticut State Employees' Campaign Pledge Form 
 Last Name First Name Employee #
Easy Payroll Deduction
Constitutional Officer? Number of Pay Periods:
The whole dollar amount per pay period I pledge: $ .00 Total $ .00 Annually
 Payroll Deduction Charity Designations: You may only designate to charities listed in the 2016 CSEC Directory.  Any fund not designated to a charity will go into the Campaign's general fund.  Please visit www.csec.ct.gov for full listing of federations and all other charities.
Federation Name
Charity Name
Deduction Designations: $ .00
Please fill out the Easy Payroll Deduction section completely.
Charity Name Annual $ Amt. Charity Code
Total dollar amount
Donor Acknowledgement Option

      Recognition Contribution Form
I, Last Name First Name , am making a donation
on behalf of: Last Name First Name    

 Street Number Street City/Town            
 State Zip Code                      

in the amount of : $
Please fill out the Easy Payroll Deduction section completely.

 Donation is made to the following organization: 
 Charity Name
Charity Code

Please turn in form to your agency coordinator or fax to (860) 859-4156

I hereby authorize the State Comptroller to withhold my charitable deduction listed above beginning January 2017. Minimum gift of $1 required for payroll deduction. The CSEC has not provided goods or services as whole or partial consideration for any contributions made by payroll deduction.
SIGNATURE (Needed to authorize payroll deduction)
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