Workplace Giving Form

I hereby authorise the above deduction to West Moreton Health Foundation to occur every fortnight from the first available pay after receipt of this authorisation. While not all deductions are tax deductible, I hereby acknowledge that this is my responsibility to consult with a financial adviser regarding the tax implications of all donations that I have authorised. I further authorise West Moreton Health Payroll Services to amend the arrangements for the processing of payroll deductions and nominated fixed amounts from my fortnightly salary and wage payments in accordance with my instructions above. Further, I acknowledge and accept responsibility for any consequence arising if any of the nominated deductions are unable to be made due to insufficient net pay in any of the nominated engagements. I consent for West Moreton Health Foundation to receive the completed form for the purposes of payroll giving communications and sending an End of Financial Year donation receipt to me, and to keep me informed of news and promotions relating to the West Moreton Health Foundation. Privacy disclaimer: Personal information collected by the Department of Health or West Moreton Health Service is handled in accordance with the Information Privacy Act 2009. The personal information provided by you will be securely stored and made available only to appropriately authorised officers of the WMHS (or its agents). Personal information recorded on this form will not be disclosed to other parties without your consent, unless required by law.

I understand this nominated amount will be deducted every fortnight from the first available pay after the receipt of this authorisation and will continue until withdrawn by me.