2013
2013 Connecticut State Employees' Campaign Pledge Form
Last Name
First Name
Employee #
Agency
Academic Awards, Board For State
Accountancy, State Board of
Administrative Services, Dept Of
African American Affairs Commission
Aging, Connecticut Commission on
Agricultural Experiment Station
Agriculture, Dept Of
Attorney General, Office Of The
Auditors Of Public Accounts
Banking, Dept Of
Blind, Board Of Education & Services For The
Child Advocate, Office of
Children & Families, Dept Of
Children, Commission On
Claims Commissioner, Office Of The
Community College, Asnuntuck
Community College, Capital
Community College, Gateway
Community College, Housatonic
Community College, Manchester
Community College, Middlesex
Community College, Naugatuck Valley
Community College, Northwestern CT
Community College, Norwalk
Community College, Quinebaug Valley
Community College, Three Rivers
Community College, Tunxis
Community Colleges, Board Of Trustees
Comptroller, Office Of The State
Connecticut Development Authority
Connecticut Housing Finance Authority
Connecticut Innovations, Inc
Connecticut Lottery Corporation
Connecticut State University, Bd Of Trustees
Connecticut State University, Central
Connecticut State University, Eastern
Connecticut State University, Southern
Connecticut State University, Western
Connecticut Technical High School System, Abbott-Danbury
Connecticut Technical High School System, Aviation Tech - Hartford
Connecticut Technical High School System, Aviation Tech - Stratford
Connecticut Technical High School System, Bristol T.E.C. - Bristol
Connecticut Technical High School System, Bullard-Havens - Bridgeport
Connecticut Technical High School System, Cheney - Manchester
Connecticut Technical High School System, Ellis - Danielson
Connecticut Technical High School System, Goodwin - New Britain
Connecticut Technical High School System, Grasso - New Britain
Connecticut Technical High School System, Kaynor - Waterbury
Connecticut Technical High School System, Norwich - Norwich
Connecticut Technical High School System, O’Brien - Ansonia
Connecticut Technical High School System, Platt - Milford
Connecticut Technical High School System, Prince - Hartford
Connecticut Technical High School System, Vinal - Middletown
Connecticut Technical High School System, Whitney - Hamden
Connecticut Technical High School System, Wilcox - Meriden
Connecticut Technical High School System, Windham - Willimantic
Connecticut Technical High School System, Wolcott - Torrington
Connecticut Technical High School System, Wright - Stamford
Consumer Counsel, Office Of
Consumer Protection, Dept Of
Core-CT Project
Correction, Dept Of
Correctional Enterprises
Criminal Justice, Division Of
Culture and Tourism, CT Commission on
Deaf And Hearing Impaired, Commission On
Developmental Services, Dept Of
Disabilities, Protection And Advocacy For Persons With
Economic and Community Development, Dept Of
Education, Dept Of
Educational Technology, Connecticut Commission For
Elections Enforcement Commission, State
Emergency Management and Homeland Security, Dept Of
Environmental Protection, Dept Of
Environmental Quality, Council On
Ethics, Office of State
Fire Prevention And Control, Commission On
Firearms Permit Examiners, Board Of
Freedom Of Information Commission
Governor's Office
Health Care Access, Office Of
Healthcare Advocate, Office Of The
Higher Education, Dept Of
Human Rights And Opportunities, Commission On
Information Technology, Dept Of
Insurance And Risk Management Board
Insurance Dept
Judicial Branch
Judicial Review Council
Judicial Selection Commission
Labor Dept
Latino And Puerto Rican Affairs, Commission On
Legislative Branch
Lieutenant Governor, Office Of The
Marshal Commission, State
Medical Examiner, Office Of The Chief
Mental Health & Addiction Services, Dept Of
Military Dept
Motor Vehicles, Dept Of
Parole, Board Of
Police Officer Standards and Training Council
Policy And Management, Office Of
Probate Court Administration
Properties Review Board, State
Property Rights, Office Of Ombudsman For
Psychiatric Security Review Board (DMHAS)
Public Defender Services, Division Of
Public Health, Dept Of
Public Safety, Dept Of
Public Utility Control, Dept Of
Public Works, Dept Of
Revenue Services, Dept Of
Secretary Of The State, Office Of
Siting Council, Connecticut
Social Services, Dept Of
Soldiers', Sailors', And Marines' Fund
Special Revenue, Division Of
State Library
Teachers' Retirement Board
Transportation, Dept Of
Treasurer, Office Of The State
University of Connecticut
University Of Connecticut Health Center
Veterans' Affairs, Dept Of
Victim Advocate, Office Of The
Women, Permanent Commission On The Status Of
Workers' Compensation Commission
Workforce Competitiveness, Office For
Easy Payroll Deduction
Constitutional Officer?
Yes
No
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 2013 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
America's Charities
Community Health Charities of New England
Earth Share of New England
Global Impact
Greater Hartford Arts Council
Independent Charities of America
Middlesex United Way, Inc.
Neighbor To Nation
Partners for a Better World
Pool of Undesignated Funds
United Way of Central & Northeastern CT
United Way of Coastal Fairfield County
United Way of Greater New Haven
United Way of Greater Waterbury
United Way of Greenwich
United Way of Meriden and Wallingford
United Way of Milford
United Way of Naugatuck and Beacon Falls
United Way of Northwest Connecticut, Inc.
United Way of Southeastern Connecticut
United Way of Southington, Inc.
United Way of West Central Connecticut
United Way of Western Connecticut
Charity Name
Please select fed name first.
Deduction Designations: $
.00
Please fill out the Easy Payroll Deduction section completely.
Charity Name
Annual $ Amt.
Charity Code
Total dollar amount
Donor Acknowledgement Option
Please release my name, workplace address and pledge amount to the charities to which I have designated.
I do not wish to receive an acknowledgement from the charities to which I have designated my pledge.
Use Recognition Contribution Form
Recognition Contribution Form
I,
Last Name
First Name
, am making a donation
on behalf of:
Last Name
First Name
Send acknowledgement to above named
To the family of C/O:
Address
Street Number
Street
City/Town
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
I wish to be named on the confirmation message to the individual of this donation.
I do not wish to be named on the confirmation message to the individual of this donation.
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 2014. 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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