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We Can't Do It Without You! Make Your Pledge Today We can’t do it without you! Make your pledge today. maine.gov/msecca/ msecca Pledge Form Thank You! Return this form to your department’s MSECCA coordinator or pledge online at maine.gov/msecca/ A. Contact Info Name TAMS ID# Department Email B. Payment Method (Please check one) Payroll Deduction $ x 26 pay periods = $ (amount per pay period) Total (amount per pay period x 26 pay periods per year) Single Payment Cash or Check $ (if check, make payable to MSECCA) Total C. Payroll Deduction Authorization (Please check one & sign) I hereby authorize my employer, the State of Maine, to : Current Employee: deduct the amount shown above from my pay each pay period, starting with the first pay period in January and ending with the last pay period in December; OR New Employee: deduct the amount shown above from my pay each pay period, starting with the first pay period after I begin state employment, and ending with the last pay period in December. I understand that I can revoke this authorization at any time by providing written notice. Signature Date D. Designations Please be sure to enter the correct code and name for each federation or charity designated. You may list additional charities by attaching a separate sheet of paper to this pledge form. $ Code# Name $ Code# Name $ Code# Name $ Code# Name $ Code# Name Or designate a charity of your choice that is not listed in the donor guide. There is a minimum donation of $100 for each charity not listed in this guide. $ Name of Charity Contact Name & Phone# (must be a 501 (c)(3) organization) Address Web Address $ Total * This total should equal the total entered in section B. Undesignated pledges will be distributed to all MSECCA participating federations. E. Acknowledgement Do you wish to receive a gift acknowledgement from charities? Yes No If yes, please provide your address below: Home Address City State Zip Questions? Visit maine.gov/msecca/ for more info and to contact your department’s MSECCA coordinator. Diabetes Research Institute Foundation, Inc . 71473 Crohn’s & Colitis Foundation of America, Inc . America’s Best Charities - 71800 Dress for Success Worldwide. 71464 New England Chapter . 70605 Feeding the hungry. Sheltering the homeless. Protecting the Father Flanagan’s Boys’ Home . 71442 Cystic Fibrosis Foundation, Northern children and healing the sick. America’s finest independent Feed The Children . 71403 New England Chapter . 70606 charities. Working with you to share--the American way. FIRST . 71422 Depression and Bipolar Support Alliance . 70654 800-477-0733 www.independentcharities.org (1%) Food Allergy Research & Education, Inc . 71496 Easter Seals . 70655 Foster Care To Success Foundation . .. 71423 Endometriosis Association. 70656 ASPCA: American Society for the Prevention Give Kids The World . 71457 Epilepsy Foundation of America . 70634 of Cruelty to Animals . 71801 Hole In The Wall Gang Fund, The . 71438 HelpMeSee . 70658 Abandoned Children’s Fund. 71829 Human Rights Campaign Foundation . 71453 Huntington’s Disease Society of America, Alex’s Lemonade Stand Foundation. 71830 I Have A Dream Foundation® . 71492 MA Chapter/Maine . 70631 Alzheimer’s Foundation of America . 71820 International Planned Parenthood Federation, JDRF, Northern New England Branch . 70607 American Association for Cancer Research . 71802 Western Hemisphere . 71488 Leukemia & Lymphoma Society - America’s VetDogs - the Veteran’s K-9 Corps, Inc . 71821 Make-A-Wish Foundation® of America . 71409 Massachusetts Chapter, The . 70627 Big Cat Rescue Corp . 71831 Melanoma Research Foundation . 71497 Lupus Foundation of America .. 70659 Canine Companions for Independence . 71803 Mercy Housing . 71448 Maine Family Planning. 70615 Canine Wounded Heroes . 71840 Mothers Against Drunk Driving . 71446 March of Dimes Foundation, Maine . 70620 Catholic Relief Services - USCCB . 71804 Multiple Sclerosis Association of America . 71474 Mental Health America . 70660 Children’s Food, Healthcare, Shelter NAACP Foundation . 71458 Muscular Distrophy Association, Inc ., Northeast Division .70611 and Education Fund . 71818 NAACP Legal Defense and Educational Fund . 71413 Myasthenia Gravis Foundation of America . .. 70661 Concerns of Police Survivors, Inc . (COPS) . 71822 NARAL Pro-Choice America Foundation . 71427 NAMI (National Alliance on Mental Illness. .. 70662 Correctional Peace Officers Foundation . 71805 National Black Child Development Institute . .. 71407 National Blood Clot Alliance . 70609 Delta Research and Educational Foundation . 71832 National Down Syndrome Society . 71475 National Council on Alcoholism & Drug Diabetes Action Research and Education Foundation . 71806 National Fallen Firefighters Foundation . 71447 Dependence (NCADD) . 70663 Disabled American Veterans (DAV) Charitable National Trust for Historic Preservation National Foundation for Cancer Service Trust . 71807 in the United States . 71408 Research-Cancer Research America . 70618 Dogs Deserve Better . 71833 Ovarian Cancer Research Fund . 71498 National Headache Foundation .. 70664 Dogs for Deaf and Disabled Americans (NEADS) . 71808 PetSmart Charities, Inc . 71467 National Hemophilia Foundaiton . .. 70665 Dogs On Death Row . 71841 Population Connection . 71454 National Hospice and Palliative Care Organization . 70666 EOD Warrior Foundation . 71823 Rails-to-Trails Conservancy . .. 71411 National Kidney Foundation, Northeast. 70619 Fisher House Foundation . 71809 Reading Is Fundamental, Inc . (RIF) . 71418 National Multiple Sclerosis Society . 70612 Fund for Animals, The. 71824 Ronald McDonald House Charities. 71468 National Ovarian Cancer Coalition . 70667 Gary Sinise Foundation . 71842 Southern Poverty Law Center . 71460 National Parkinson Founation. .. 70668 Guide Dog Foundation for the Blind . 71825 The Conservation Fund. 71415 National Psoriasis Foundation . 70669 Guide Dogs for the Blind, Inc . 71834 The LIVESTRONG Foundation . 71416 National Stroke Association . .. 70670 Habitat for Humanity . 71826 Thurgood Marshall College Fund. 71494 Pancreatic Cancer Action Network . 70671 Habitat for Humanity International . 71810 Tuberous Sclerosis Alliance. 71425 Parkinson’s Disease Foundation . 70672 Homes For Our Troops . .. 71811 Wounded Warrior Project, Inc . 71417 Pet Partners . 70673 Hope For The Warriors . 71835 Pine Tree Society . 70614 Humane Society of the United States . 71827 Community Health Charities - 70600 Prevent Blindness (National Society Lutheran World Relief . 71836 to Prevent Blindness . 70675 Mr . Holland’s Opus Foundation . 71837 Partnering with Maine’s most trusted health charities to deliver credible health information, community focused volunteer Resolve: The National Infertility Association . 70676 Navy SEAL Foundation, Inc . 71838 SeriousFun Children’s Network . 70677 Operation Homefront . 71814 activities and efficient charitable giving in the workplace. 207-799-4666 www.healthcharitiesmaine.org (7.1%) Shatterproof . 70686 Parkinson’s Research - The Michael J . Fox Sickle Cell Disease Association of America . 70678 Foundation for Parkinson’s Research . 71813 AIDS Research Foundation (amfAR) . 70637 Smile Train . 70679 Paws4Vets . 71843 Snowball Express . .. 70680 Planned Parenthood Federation of America . 71815 Alliance for Cancer Gene Therapy . 70632 ALS Association Northern New England Chapter, The . 70624 Spina Bifida Association of America . 70681 Semper Fi Fund . 71812 St . Jude Children’s Research Hospital Shriners Hospitals for Children. 71816 Alzheimer’s Association, Maine Chapter . 70601 American Diabetes Association New England (serving CT, NH, MA, ME, & RI). 70623 Special Operations Warrior Foundation . .. 71828 Susan G . Komen . 70682 Veteran Tickets Foundation . 71839 Region-Maine . 70602 American Hearing Research Foundation . 70639 Tourette Association of America . 70683 Veterans of Foreign Wars Foundation. 71817 Variety - the Children’s Charity International . 70684 Wreaths Across America . 71819 American Heart Association, Founders Affiliate. 70617 American Kidney Fund . .. 70625 ZERO - The End of Prostrate Cancer . 70685 America’s Charities - 71400 American Liver Foundation, New England Division . 70633 American Lung Association of New England, Inc . EarthShare New England - 71600 Working to build strong communities. Addressing needs of dba ALA of Maine . 70603 children, families, communities through member programs, One gift helps protect your environment, health, wildlife, and American Parkinson Disease Association . 70641 natural resources -- locally, nationally, and internationally. by helping employers and employees to support our member Arthritis Foundation, New England Region .. 70604 charities programs. 800-458-9505 www.charities.org One environment, one simple way to care for it. Asthma & Allergy Foundation of America, 877-207-5756 www.earthsharenewengland.org (8.4%) (4.3%) New England Chapter . 70642 Autism Speaks . 70643 Alzheimer’s Disease Research . 71493 American Farmland Trust . .. 71602 American Brain Foundation . 71410 Be the Match Foundation . .. 70644 Black Women’s Health Imperative . 70645 African Wildlife Foundation . 71663 American Center for Law and Justice . 71478 American Bird Conservancy . 71605 American Civil Liberties Union Foundation. 71462 Cancer Research Institute . .. 70646 CaringBridge . 70630 American Forests . 71645 Amnesty International USA . 71402 American Rivers . 71664 AMVETS National Service Foundation . 71420 Cerebral Palsy Foundation . 70647 Childhood Obesity - Alliance for a Appalachian Mountain Club . 71638 Boy Scouts of America . .. 71404 Beyond Pesticides
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