Fillable 2010-03 Attachment Combined Federal Campaign Form (U.S. Office of Personnel Management)

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2010-03 Attachment Combined Federal Campaign Form (U.S. Office of Personnel Management)

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The 2010-03 Attachment Combined Federal Campaign Form (U.S. Office of Personnel Management) form is 3 pages long and contains:

  • 3 signatures
  • 15 check-boxes
  • 141 other fields

Country of origin: US
File type: PDF

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Page 1 of 4
OPM 1654
Revised January 2010
PLEASE USE BALL POINT PEN & WRITE FIRMLY
COPY #1 – PAYROLL OFFICE
CFC Campaign Number
City/State Code:
ATTENTION PAYROLL OFFICES:
Only use this number to identify the local
campaign.
Enter Last Name, First Name, and MI
Check (if applicable)
Federal Agency and Office SSN/ Employee ID
Civilian
Military
Work Address & Zip Code
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
MILITARY PAYROLL
Branch of Service?
$
X 12 months
$
Civilian Payroll
$
X 26 pay periods
$
Check / Cash Amt.: $
Check Number:
(make check payable to the Combined Federal Campaign)
Date of Contribution:
Charity Code Annual Amount
$
$
$
$
$
CFC organizations do not provide goods or services in whole or partial consideration for
any contributions made to the organizations via this pledge card.
DESIGNATED GIFT: To designate to one or more charities or
federated groups, fill in the charity code(s) and dollar amounts
above.
PAYROLL DEDUCTION AUTHORIZATION
I hereby authorize any agency of the United States Government by which I may be employed
during 2011 to deduct the amount(s) shown above from my pay each pay period during the
calendar year 2011 starting with the first pay period that begins in January and ending with
the last pay period that begins in December, and to pay the amounts so deducted to the
Combined Federal Campaign shown above. I understand that this authorization may be
revoked by me in writing at any time before it expires.
Signature Date
See reverse side for information on volunteer opportunities in your community.
RECOGNITION OPTIONS
Release Pledge Amount
Box must be checked
( Every designated charity will be notified of your gift amount.)
In order to protect your information and maintain confidentiality, each field below requires
two-steps. Your information will NOT be released unless the field is filled in AND the box
is checked. By completing the line(s) below AND checking the box, your name along
with the corresponding information will be released to your designated charities.
Home Address
Box must be checked
Home E-mail
Box must be checked
Print Form
Save Form
Clear Form
click to sign
signature
click to edit
Page 2 of 4
OPM 1654
Revised January 2010
COPY #2 – For Central Receipt Point
PLEASE USE BALL POINT PEN & WRITE FIRMLY
CFC Campaign Number
City/State Code:
ATTENTION PAYROLL OFFICES:
Only use this number to identify the local
campaign.
Enter Last Name, First Name, and MI
Check (if applicable)
Federal Agency and Office SSN/ Employee ID
Civilian
Military
Work Address & Zip Code
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
MILITARY PAYROLL
Branch of Service?
$
X 12 months
$
Civilian Payroll
$
X 26 pay periods
$
Check / Cash Amt.: $
Check Number:
(make check payable to the Combined Federal Campaign)
Date of Contribution:
Charity Code Annual Amount
$
$
$
$
$
CFC organizations do not provide goods or services in whole or partial consideration for
any contributions made to the organizations via this pledge card.
DESIGNATED GIFT: To designate to one or more charities or
federated groups, fill in the charity code(s) and dollar amounts
above.
RECOGNITION OPTIONS
Release Pledge Amount
Box must be checked
( Every designated charity will be notified of your gift amount.)
In order to protect your information and maintain confidentiality, each field below requires
two-steps. Your information will NOT be released unless the field is filled in AND the box
is checked. By completing the line(s) below AND checking the box, your name along
with the corresponding information will be released to your designated charities.
Home Address
Box must be checked
Home E-mail:
Box must be checked
See reverse side for information on volunteer opportunities in your community.
PAYROLL DEDUCTION AUTHORIZATION
I hereby authorize any agency of the United States Government by which I may be employed
during 2011 to deduct the amount(s) shown above from my pay each pay period during the
calendar year 2011 starting with the first pay period that begins in January and ending with
the last pay period that begins in December, and to pay the amounts so deducted to the
Combined Federal Campaign shown above. I understand that this authorization may be
revoked by me in writing at any time before it expires.
Signature Date
click to sign
signature
click to edit
Page 3 of 4
OPM 1654
Revised January 2010
PLEASE USE BALL POINT PEN & WRITE FIRMLY
CFC Campaign Number
City/State Code:
ATTENTION PAYROLL OFFICES:
Only use this number to identify the local
campaign.
Enter Last Name, First Name, and MI
Check (if applicable)
Federal Agency and Office SSN/ Employee ID
Civilian
Military
Work Address & Zip Code
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
MILITARY PAYROLL
Branch of Service?
$
X 12 months
$
Civilian Payroll
$
X 26 pay periods
$
Check / Cash Amt.: $
Check Number:
(make check payable to the Combined Federal Campaign)
Date of Contribution:
Charity Code Annual Amount
$
$
$
$
$
CFC organizations do not provide goods or services in whole or partial consideration for
any contributions made to the organizations via this pledge card.
DESIGNATED GIFT: To designate to one or more charities or
federated groups, fill in the charity code(s) and dollar amounts
above.
RECOGNITION OPTIONS
Release Pledge Amount
Box must be checked
( Every designated charity will be notified of your gift amount.)
In order to protect your information and maintain confidentiality, each field below requires
two-steps. Your information will NOT be released unless the field is filled in AND the box
is checked. By completing the line(s) below AND checking the box, your name along
with the corresponding information will be released to your designated charities.
Home Address
Box must be checked
Home E-mail:
Box must be checked
See reverse side for information on volunteer opportunities in your community.
PAYROLL DEDUCTION AUTHORIZATION
I hereby authorize any agency of the United States Government by which I may be employed
during 2011 to deduct the amount(s) shown above from my pay each pay period during the
calendar year 2011 starting with the first pay period that begins in January and ending with
the last pay period that begins in December, and to pay the amounts so deducted to the
Combined Federal Campaign shown above. I understand that this authorization may be
revoked by me in writing at any time before it expires.
Signature Date
COPY #3 – Contributor's Copy- Keep For Personal Tax Records
click to sign
signature
click to edit
Page 4 of 4
Privacy Act Notice
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.
Find a Volunteer Opportunity
The USA Freedom Corps Volunteer Network can help you access service opportunities near your home or office, across the country, or
overseas. Just go to www.volunteer.gov, enter geographic information, such as zip code or state, and your area of interest to find out how you
can get involved.
OPM 1654
Revised January 2010
COPY #3 – Contributor's Copy- Keep For Personal Tax Records
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2010-03 Attachment Combined Federal Campaign Form (U.S. Office of Personnel Management)

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Completed 26 July 2020

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