Fillable Opm1654-b 2018 Combined Federal Campaign Federal Retiree Pledge Form

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Opm1654-b 2018 Combined Federal Campaign Federal Retiree Pledge Form

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The Opm1654-b 2018 Combined Federal Campaign Federal Retiree Pledge Form form is 1 page long and contains:

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  • 9 check-boxes
  • 47 other fields

Country of origin: US
File type: PDF

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OPM Form 1654-B
OMB No. 3206-0271
2018 Combined Federal Campaign
Federal Retiree Pledge Form
Please ll in with black ink. Sections marked with are mandatory.
Online pledges are accepted through Jan. 11, 2019, by visiting opm.gov/ShowSomeLoveCFC.
All paper pledge forms must be postmarked by Jan. 11, 2019. Keep a copy of this form before sending
it to: CFC Processing Center, P.O. Box 7820 Madison, WI 53707-7820.
CFC organizations do not provide goods or services in whole or partial consideration for any contributions
made to the organizations via this pledge.
Donor Information
Primary Email Address
(nonfederal email provided to charities, if released)
Secondary Email Address
(alternate email address used by CCA if primary address fails)
First Name Last Name
Retiree Type Home Zip Code or APO
Military (DFAS) Civilian (OPM)
Judicial
Pledge Information
Allotment Source Amount Per Deduction Total Annual Gift Charity Designation
Annuity
SSN:
(only required if electing annuity)
– –
Monthly x12
$ $
(multiply amount per
deduction by the payroll
frequency to determine
your total annual gift)
CFC Charity Code
Annual Amount
$
$
$
$
$
You must select one or more charities or federated groups
to receive your donation. Identify your selected charities by
entering their corresponding five-digit code along with the
total dollar amount you want each charity to receive. The
total annual gift from the left must match the total pledged
to charities below.
If you would like to donate to more than five charities,
please visit opm.gov/ShowSomeLoveCFC to complete an
online donation or attach another copy of this form and label
your forms 1 of X, 2 of X, etc. The total annual contribution
amount should appear on copy 1 of X.
Check
Make checks payable to
“Combined Federal Campaign”
and attach to this form.
N/A
$
Check Amount
Authorization
If I chose annuity reduction as my payment source, I hereby authorize any agency of the United States
government from which I may be retired during 2019 to deduct the amount(s) shown above from my
annuity each payment period during the calendar year 2019. These deductions will start with the first
annuity payment period following Jan. 15, 2019 and ending with the last allotment period that includes
Jan. 15 of the following year. I authorize the government to pay the amounts deducted to the
Combined Federal Campaign. I understand that this authorization may be revoked by me in writing at
any time before it expires. I also acknowledge that I have the right to receive a notification if the
amount(s) scheduled to be transferred differ(s) from the amount(s) displayed above.
SIGNATURE
DATE
TOTAL ANNUAL
CONTRIBUTION:
$
Information Release (optional)
By checking each box below, I authorize the CFC to release my name and the following to my designated charity(ies):
My pledge amount
My home address
(If opting to release your information, please provide your home address below.)
My email
Home Address City State Zip Code
Individuals may pledge online at opm.gov/ShowSomeLoveCFC and may contact the CFC Help Desk Monday through Friday from 8 a.m. until 6 p.m.
Central Time at 800-797-0098 (toll-free) or 608-237-4898 (local/international) with questions about the pledge process.
click to sign
signature
click to edit
Combined Federal Campaign
Privacy Act Statement
Pursuant to 5 U.S. C. 522a(e)(3), this Privacy Act Statement informs you why OPM is requesting information on this form.
AUTHORITY:
OPM is authorized to collect the information on this form based upon the authority provided in Executive Order (EO) 12353
(March 23, 1982), as amended by EO 13743 (October 13, 2016), and 5 CFR 950 (January 1, 2017). In addition, Executive Order 9397
(November 22, 1943), as amended by EO 13478 (November 18, 2008), permits us to collect your Social Security Number (SSN).
PURPOSE:
The information you provide is primarily collected and used by OPM to accurately receive, process, acknowledge, and account
for your donation to the Combined Federal Campaign (CFC); and to make payments to the charitable organizations to which you
choose to donate.
ROUTINE USES:
The information we collect from you may be disclosed as a “routine use” to your payroll service provider, if you have chosen to
make a recurring gift via payroll deduction; or to your credit card company, bank, or other nancial institution for a one-time or
recurring gift (using the CFC’s online option) via credit card, electronic check, or automatic deduction from your nancial
account. With your authorization, we may also share the information you provide to us with local, national, or international
charitable organizations or federations. In addition, we may share your information as a “routine use” with other external
entities, such as law enforcement or state and federal tax authorities, when the disclosure is necessary to investigate a violation
or potential violation of civil or criminal law. A complete list of routine uses can be found in the system of records notice titled
“Central-20 National CFC System of Records.”
CONSEQUENCES OF FAILING TO PROVIDE INFORMATION:
Providing this information, including your SSN, is voluntary; however, without your signature and all of the information requested,
it may not be possible for us to make this gift on your behalf, and we may suspend this pledge. In addition, if you do not provide
any of the requested information, we may not be able to process your request for a payroll deduction. 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.
PUBLIC BURDEN STATEMENT:
We think providing this information takes an average of 30 minutes per response to complete, including the time for reviewing
instructions, getting the needed data, and reviewing the completed information collection title. Send comments regarding our
estimate or any other aspect of the information collection, including suggestions for reducing completion time, to the Oce of
Personnel Management (OPM), OPM Forms Ocer (3206-0271), Washington, D.C. 20415-7900. The OMB number 3206-0271 is
valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
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Opm1654-b 2018 Combined Federal Campaign Federal Retiree Pledge Form

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Completed 5 December 2019

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