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Fillable Printable OPM Form 1654

Fillable Printable OPM Form 1654

OPM Form 1654

OPM Form 1654

SignatureDate
OPM 1654
Revised May 2014
o
In addition to my contact information, I authorize the CFC to release the amount of my pledge to the
charity(ies) I designated above.
PAYROLL DEDUCTION AUTHORIZATION
Ihereby authorizeanyagency ofthe UnitedStatesGovernment bywhichImaybeemployed during2015todeductthe
amount(s) shown above from my pay each pay period duringthe calendar year2015 startingwith the firstpay period that
begins in January and ending withthe last pay period that beginsin December, and to pay the amounts so deducted to the
Combined FederalCampaignshownabove.Iunderstandthatthisauthorizationmayberevokedbymeinwritingatany
time before it expires.
Any information you enter below will be released, along with your name, to the charity(ies) to
which you made a pledge. Do not enter your work address or email.
Home Address:
Personal Email Address:
ALLOTMENT SOURCE
DESIGNATED GIFT: To designate to one or more charities or federated
groups, fill in the charity code(s) and dollar amounts above. Undesignated
gifts are distributed among all organizations in proportion to their pledges.
COPY #1 - PAYROLL OFFICE
PLEASE USE BALL POINT PEN & WRITE FIRMLY
CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to
the organizations via this pledge card.
INFORMATION RELEASE (OPTIONAL)
ATTENTION PAYROLL OFFICES:
Use this number only to identify the local campaign.
City/State Code:
CFC Campaign Number
(make check payable to the Combined Federal Campaign)
Work Phone Number
SSN/Employee ID
Last Name, First Name, MI
oCivilian
oMilitary
$
CASH/CHECK
Amount:
$
Check Number:
MILITARY PAYROLL
Branch of Service?
ANNUAL AMT
$
$
$
AMOUNT
INTERVAL
TOTAL GIFT
$
$
x 12 months
CIVILIAN PAYROLL
$
x 26 pay periods
CONTRIBUTION: Fill in the blank showing the amount of your payroll allotment, cash or check contribution. Write
in the total of your annual contribution in the space provided.
Federal Agency and Office
$
$
CHARITY CODE
SignatureDate
OPM 1654
Revised May 2014
$
Check Number:
$
Home Address:
Ihereby authorizeanyagency ofthe UnitedStatesGovernment bywhichImaybeemployed during2015todeductthe
amount(s) shown above from my pay each pay period duringthe calendar year2015 startingwith the firstpay period that
begins in January and ending withthe last pay period that beginsin December, and to pay the amounts so deducted to the
Combined FederalCampaignshownabove.Iunderstandthatthisauthorizationmayberevokedbymeinwritingatany
time before it expires.
Personal Email Address:
o
In addition to my contact information, I authorize the CFC to release the amount of my pledge to the
charity(ies) I designated above.
(make check payable to the Combined Federal Campaign)
DESIGNATED GIFT: To designate to one or more charities or federated
groups, fill in the charity code(s) and dollar amounts above. Undesignated
gifts are distributed among all organizations in proportion to their pledges.
CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to
the organizations via this pledge card.
INFORMATION RELEASE (OPTIONAL)
Any information you enter below will be released, along with your name, to the charity(ies) to
which you made a pledge. Do not enter your work address or email.
PAYROLL DEDUCTION AUTHORIZATION
CASH/CHECK
Amount:
$
Branch of Service?
$
CIVILIAN PAYROLL
$
x 26 pay periods
$
$
PLEASE USE BALL POINT PEN & WRITE FIRMLY
Last Name, First Name, MI
oCivilian
oMilitary
COPY #2 - CENTRAL RECEIPT POINT
Work Phone Number
CONTRIBUTION: Fill in the blank showing the amount of your payroll allotment, cash or check contribution. Write
in the total of your annual contribution in the space provided.
ALLOTMENT SOURCE
AMOUNT
INTERVAL
TOTAL GIFT
CHARITY CODE
ANNUAL AMT
MILITARY PAYROLL
$
x 12 months
$
$
ATTENTION PAYROLL OFFICES:
Use this number only to identify the local campaign.
CFC Campaign Number
City/State Code:
Federal Agency and Office
SignatureDate
OPM 1654
Revised May 2014
Home Address:
Ihereby authorizeanyagency ofthe UnitedStatesGovernment bywhichImaybeemployed during2015todeductthe
amount(s) shown above from my pay each pay period duringthe calendar year2015 startingwith the firstpay period that
begins in January and ending withthe last pay period that beginsin December, and to pay the amounts so deducted to the
Combined FederalCampaignshownabove.Iunderstandthatthisauthorizationmayberevokedbymeinwritingatany
time before it expires.
Personal Email Address:
o
In addition to my contact information, I authorize the CFC to release the amount of my pledge to the
charity(ies) I designated above.
Any information you enter below will be released, along with your name, to the charity(ies) to
which you made a pledge. Do not enter your work address or email.
PAYROLL DEDUCTION AUTHORIZATION
$
Check Number:
$
CASH/CHECK
Amount:
$
(make check payable to the Combined Federal Campaign)
DESIGNATED GIFT: To designate to one or more charities or federated
groups, fill in the charity code(s) and dollar amounts above. Undesignated
gifts are distributed among all organizations in proportion to their pledges.
CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to
the organizations via this pledge card.
INFORMATION RELEASE (OPTIONAL)
Branch of Service?
$
CIVILIAN PAYROLL
$
x 26 pay periods
$
$
PLEASE USE BALL POINT PEN & WRITE FIRMLY
Last Name, First Name, MI
oCivilian
oMilitary
COPY #3 - CONTRIBUTOR'S COPY - KEEP FOR PERSONAL TAX RECORDS
Work Phone Number
CONTRIBUTION: Fill in the blank showing the amount of your payroll allotment, cash or check contribution. Write
in the total of your annual contribution in the space provided.
ALLOTMENT SOURCE
AMOUNT
INTERVAL
TOTAL GIFT
CHARITY CODE
ANNUAL AMT
MILITARY PAYROLL
$
x 12 months
$
$
ATTENTION PAYROLL OFFICES:
Use this number only to identify the local campaign.
CFC Campaign Number
City/State Code:
Federal Agency and Office
COPY #3 - CONTRIBUTOR'S COPY - KEEP FOR PERSONAL TAX RECORDS
Executive Order No. 12353 authorizes the U.S. Office of Personnel Management to conduct fund raising activities and to establish procedures for collecting information related to
such activities.
Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security Number (SSN). This collected information will be disclosed to organizations maintaining the
accounting of contributions and to your payroll office.
Additional disclosure may be made to the Department of Treasury to make proper financial adjustments to a court or another agency when the government is party to a suit; and to
the Internal Revenue Service and state and local taxing authorities regarding income tax returns.
The furnishing of the SSN, along with other data requested, is voluntary, However, failure to furnish any of the requested information may result in errors or noncompliance with
your request for a payroll deduction by your agency.
If you are making a one-time, lump-sum gift and, therefore, not using the payroll deduction method of payment, you are not required to furnish your SSN.
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