Payroll Deduction Form

Be part of our mission.

Enroll in convenient payroll deduction below.

Fields marked with * are required.

First Name

Last Name

Address

City

State

Zip

Phone

Email

Department

Employee ID

As a UPMC Washington, UPMC Greene, or UPMC WPG Employee, I am paid

Deduction amount per pay

If Other: Please list other amount here

Please direct my deduction to:*

Authorization

By submitting this form, I understand that I am pledging philanthropic support to Washington Greene Health Foundation. I authorize the amount indicated to be automatically deducted from my pay each pay period. I understand that if I wish to modify or discontinue my payroll deduction donations, that I can simply notify WGHF at [email protected].