OSmpe Staff Campaign Pledge Form 2016/2017 Name of Staff Member: 2016/2017 Annual Fund Pledge Yes! | willjoin other MDC staff members and help fund our programs with a pledge of: $2,500 ($96.15 per paycheck) $1,000 ($38.46 per paycheck) $500 ($19.23 per paycheck) $250 ($9.61 per paycheck) $100 ($3.84 per paycheck) $50 ($1.92 per paycheck) Other $ 6 per paycheck) One time gift of: | wish to remain anonymous in my: Pledge status ‘Amount donated | do not have a preference regarding the anonymity of my pledge status or amount donated. Payment Options | want to give through payroll deduction. Please deduct $ starting on. ‘and ending on per paycheck to futfill my pledge, | want to futfll my pledge through multiple payments on my own. | will pay $. every Please charge my credit card with payments of $. and ending every , starting VISA Mastercard ‘American Express Name on cardi Card Number: Expiration Date! CW Seourity Code: Thank you for supporting MDC in their mission to close the gaps that separate people from opportunity. You are making a real difference every day!