Heartland Dental LLC Voluntary
Payroll Deduction Authorization Form

This form should be completed in its entirety and be submitted to the Payroll Department at least two weeks prior to the effective date.

Payroll Deduction Information

Heartland Dental Foundation (HDF) – Through HDF, we are formalizing our collective passions into a unified effort that will support you as individuals and strengthen our impact locally and globally. Funds within HDF are component funds of Southeastern Illinois Community Foundation, a 501(c)(3) not-for-profit organization. For IRS purposes, all gifts are tax-deductible to the extent allowed by law. In order to ensure your gift is fully tax deductible, please note that Southeastern Illinois Community Foundation has exclusive legal control over your contribution and acknowledges that no goods or services were provided in exchange for your donation. In the event that the undersigned employee wishes to claim charitable contributions made pursuant to this agreement, this agreement shall be considered a “pledge card” made at the direction of Southeastern Illinois Community Foundation, to comply with any applicable IRS rules.

Payroll Deduction Terms

By signing below, I hereby authorize Heartland Dental LLC to make the above deductions from my wages in accordance with the above terms. I further understand and agree that deductions will be made after any mandatory taxes as well as for any employer programs in which I have enrolled, for which I am eligible, or to which I have agreed. This authorization will remain in effect until canceled by me or by payroll, and any changes will be effective based upon the payroll processing schedule. I also agree for Heartland Dental LLC to release information about me, and the payroll deductions, needed by Southeastern Illinois Community Foundation to properly administer the tax and accounting functions of the program. I certify that I am an employee of Heartland Dental LLC or Professional Corporation and understand that termination of employment will cancel deductions made under this authorization.

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Payroll Deduction Terms