OPM Form 1654-A
Donor Type
Last NameFirst Name
Primary Email Address
(official government)
Secondary Email Address
(personal email to provide to charities, if released)
Office/Work Zip Code or APO
Your Office/UnitFederal Agency
(e.g., U.S. Army, U.S. Customs and Border Patrol)
Your Department
(e.g., Defense, Homeland Security, USPS)
Donor Information
Military I’m located in a foreign territory without a ZIP CodeCivilian Postal
- -
Allotment Source
Authorization
Pledge Information
CFC Charity Code
Annual Amount
$
$
$
$
$
TOTAL ANNUAL
CONTRIBUTION:
$
Volunteer Time
HRS
Monthly x12
Semi-Monthly x24
Bi-Weekly x26
Payroll
Check
Amount Per Deduction Total Annual Gift Charity Designation
$ $
$
Check Payroll Frequency:SSN:
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.
(multiply amount per
deduction by the payroll
frequency to determine
your total annual gift)
Check AmountMake checks payable to
“Combined Federal Campaign”
and attach to this form.
(only required if electing payroll)
N/A
000– 00– 0000
If I chose payroll deduction as my payment source, I hereby authorize any agency of the United
States Government by which I may be employed during 2019 to deduct the amount(s) shown
above from my pay each pay period. My deductions will be in effect for one full year starting with
the first pay period after January 15 and ending with the last pay period that includes January 15
of the following year. I authorize my payroll service provider to pay the amounts shown 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. If I chose
check, I hereby authorize Give Back Foundation on behalf of the Combined Federal Campaign to
process my paper check as an electronic funds transfer (EFT) for the payment amount elected.
SIGNATURE
DATE
Information Release (optional)
By checking each box below, I authorize the CFC to release my name and the following to my designated charity(ies):
CityHome Address
State Zip Code
My pledge amount
My volunteer time
(If you do not release your volunteer commitment, please contact the charity to volunteer.)
My home address
(If opting to release your information, please provide your home address below.)
My email
(secondary/nongovernment e-mail address)
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.
2018 Combined Federal Campaign
Federal Employee 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 should be submitted to your Keyworker as early as possible to allow time for processing. Keep a
copy of this form before submitting to your Keyworker. CFC organizations do not provide goods or services in
whole or partial consideration for any contributions made to the organizations via this pledge.
click to sign
signature
click to edit
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