Payroll Deduction Authorization

Employee Name*

Email*

Title

Work Location

I would like to support my fellow St. Elmo Steak House, Harry & Izzy's, HC Tavern + Kitchen and 1933 Lounge employees with a recurring donation in the amount of:

$25 per year ($0.96 per pay period)
$50 per year ($1.92 per pay period)
$100 per year ($3.84 per pay period)
$250 per year ($9.91 per pay period)
$500 per year ($19.23 per pay period)
$1,000 per year ($38.46 per pay period)
Other Amount
One-Time Contribution

I would lke to make a one-time contribution in the amount of:

Other Amount

Per Year
Per Pay Period

Per Year

Per Pay Period

If you would like to set a stop date for this deduction, please indicate below.

example: I wish to stop payroll deduction after 3 months

Stop Current Payroll Deduction

I wish to stop my recurring donation

I would like to make this donation

in honor of
in memory of
anonymously

Name