My Contact Information First Name Employer Last Name Employer Name Payment Information Options - Select One - None -Payroll Deduction Check Cash Donor Notes Amount Per Pay Period Home Address Location/Department Name Frequency you are Paid - None -Weekly (52 times/yr) Bi-Weekly (26 times/yr) Semi-Monthly (24 times/yr) Other City Employee Number If other, what frequency: Amount of Check State - Select -Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Amount of Cash Zip Code Total Annual Contribution Email Address Office Phone Cell Phone Submit
