Salary Deduction Form

Request Type*
- New request
- Change to an existing donation
- Stop my current donation
Name:*
First Last
Title:*
Please list your name as you would like it to appear on the TERF Donor page:
Donate Anonymously
- Select if you would like to donate Anonymously
Last 4 Digits of Social Security Number (SSN):*
Branch Name:*
Personal Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

We will use this address to send you a tax write-off letter
Phone:
Email:
Recurring Donation
If ‘Other’, please enter the amount we may deduct per paycheck.
- $2 Per Paycheck
- $5 Per Paycheck
- $10 Per Paycheck
- $15 Per Paycheck
Other Amount (Recurring):
If you would like to submit a different recurring amount, please enter the amount below followed by ‘weekly’ or ‘bi-weekly’ deduction. For example: ‘$1 / weekly’
Donation Start Date
Please select the date you would like the donation to start (Friday dates only):
MM slash DD slash YYYY
By typing my name, I authorize LandCare USA LLC to deduct the amount listed above from my paycheck. I understand that this is a voluntary payroll deduction and I can change or stop this deduction at any time:*
Today's date:*
MM slash DD slash YYYY