I authorize my employer to deduct my contribution per pay period. The organization does not provide goods or services in whole or partial consideration for any contributions made to the organization by payroll deduction.

Your dollars will be directed to Community Health Charities of Nebraska (undesignated) to be distributed to member charities unless otherwise noted in this section. To designate, select the charities you would like your dollars to go to. Your gift will be distributed among these charities equally unless you indicate otherwise. The total amount designated cannot exceed the total donation amount listed above. 100% of donor-designated dollars go directly to the charity or charities you choose. Thank you for your contribution!

By checking this box and submitting this form, I authorize CHC-NE to provide this information to my employer so it can be included in my company campaign and processed accordingly.

State Office

Lincoln Office

west central office