<p> Commonwealth of Virginia Campaign PAPER PLEDGE TRANSMITTAL FORM</p><p>Date: Agency Name: </p><p>Coordinator Name: Coordinator Phone: </p><p>Agency Code: Unit/District/Inst. Code: (for VDOT, DOC, VDH)</p><p>This report is my: First Report Additional Report Final Report</p><p>This report should be mailed to: CVC/DHRM 101 N. 14th St. – 12th Floor Richmond VA 23210</p><p>CHECKLIST FOR COORDINATORS</p><p>Sort your paperwork into stacks of Cash/Check, Payroll Deduction, and Credit Card Pledges Include this transmittal sheet and keep a copy on your PC for your records to add to it later. Deposit Cash, checks, coin in CVC banks. Include a copy of cashier’s deposit slip with form. Checks should be payable to “CVC” and not to individual charity names. Do not use for Direct Giving – Checks given directly to a CVC charity.</p><p>Transmittal Summary T # $ # $ # Donors $ # Donors $ Date r Do D Prepar a nor o ed n s n o s r # s Cash/Check/ TOTAL ALL Money Orders Credit Cards PLEDGES 1 $ $ $ $ 2 $ $ $ $ 3 $ $ $ $ 4 $ $ $ $ 5 $ $ $ $ 6 $ $ $ $ 7 $ $ $ $ 8 $ $ $ $ 9 $ $ $ $ 10 $ $ $ $ YTD -- $ $ $ $ Prepared by: Verified By: This form is intended for agencies who submit multiple batches. Put the transmittal date in the first column. Then enter total donors and dollars for each set of columns – Cash/Check, Payroll Deductions, Credit Cards, and then total donors and dollars across the row. USE ONE ROW PER TRANSMITTAL BATCH. Save this form on your PC. For the next transmission, use the saved form, enter the date of the second transmittal, and complete the row for Transmittal 2. Total each column for YTD totals. This will help locate any misplaced batches.</p>