GALA PAYROLL DEDUCTION FORM The total cost for SLCH Employees this year is a special rate of $200.00 for one ticket or $400.00 for two tickets. The Gala payroll deduction option allows employees to pay for Gala tickets through a deduction in their pay checks. The deduction is $25 per ticket or $50 for two tickets, per pay period. The deduction will be over 8 pay periods starting on the pay date of June 1, 2017 and ending on the pay date of September 7, 2017. NAME: ________________________________________________________________ DEPARTMENT: ________________________________________________________ PHONE: ______________________ EMAIL: _________________________________ # OF GALA TICKETS: __________ TOTAL DEDUCTED: ____________________ [ ] I agree to have ____________ deducted from each pay check between pay dates of June 1, 2017 and September 7, 2017. This deduction has no impact on taxes. SIGNATURE: _____________________________________ DATE: ______________ Please return this form no later than May 4th to the St. Luke’s Cornwall Health System Foundation Office located on the 3rd floor of the Newburgh Campus. Or e-mail it to ndonohue@slchospital.org. If you have any questions, please contact Natassia Donohue in the Foundation Office at (845) 568-2580 or ndonohue@slchospital.org.
Please note: This year we are offering the tickets to SLCH Employees at cost which is a discount of $175 each. The tickets are non-transferable and each employee can only purchase 2 tickets. There will be no tax deductibility for these tickets.