Section 1 – Donor information

1. How to complete the 2014 GIFT FORM …National (outside the NCR) Government of Canada Workplace Charitable Campaign (GCWCC)

2. Section 1 – Donor information Important-To be Filled by the respective Canvasser Important-To be Filled by the respective Canvasser • Process: • Important Note: As the donor, you do not fill out the Canvasser Number & Organization fields. This information must be filled by the volunteer canvasser who gave you the form. • Indicate appropriate form of Salutation (Mr., Ms., Mrs., Miss, Dr., Rank or other, e.g. Reverend). • Include full name and home address (Canada Revenue Agency (CRA) requires that the address be completed for income tax receipts). • Include the date (Year-Month-Date). • Include Telephone number (Required for credit card donation).

3. Section 2 – How to distribute your gift

4. BOX 1 – Local United Way • You may choose to designate a donation to your local United Way/Centraide Process: 1. If this box is blank, enter the Identification Number for your local United Way. You can find the Identification Number by checking your GCWCC Calendar or by contacting your local United Way . 2. Indicate what amounts you would like to go where (you may enter amounts for the United Way to distribute where it will have the greatest impact and/or direct your amounts to specific impact areas). 3. If you are giving through payroll, divide your total gift by 26 and enter the amount per pay at the bottom in the ‘Payroll Deductions’ section. 4. Enter the grand total for Box 1 donations.

5. BOX 2 – Other United Way • You may choose to designate a donation to any other United Way/Centraide across Canada • If you would like to give to more than one “Other” United Way/Centraide, you must fill out another gift form per United Way Process: 1. Write the name and enter the Identification Number of the United Way. You can find the Identification Number by checking your GCWCC Calendar or by contacting your local United Way. 2. Indicate the amount you would like to give. 3. If you are giving through payroll, divide your total gift by 26 and enter the amount per pay at the bottom in the ‘Payroll Deductions’ section. 4. Enter the grand total for Box 2 donations.

6. BOX 3 – Healthpartners • You may choose to designate a donation to Healthpartners or any of its 16 member agencies. Process: 1. Indicate what amounts you would like to go where (You can choose to divide your total GIFT equally to all 16 Healthpartners member organizations by entering the dollar amount in the appropriate box or you can designate your donation to one or more specific Healthpartners member organizations). 2. If you are giving through payroll, divide your total gift by 26 and enter the amount per pay at the bottom in the ‘Payroll Deductions’ section. 3. Enter the grand total for Box 3 donations .

7. BOX 4 – Other Canadian Registered Charities You may choose to designate a donation directly to one of the 85,000 (+/-) Canadian registered charities of your choice. Please note that there is a minimum $26 per gift per charity. Process: 1. Enter the Identification Number for your local United Way – your local United Way will receive the donation and then distribute it to the specific charity you designated to. You can find the Identification Number for your local United Way by checking your Calendar or by contacting your local United Way. 2. Indicate the exact name and BN/Registration # of the charity. The charity must be registered with the Canada Revenue Agency and you must indicate the BN/Registration number of the charity. This number may be obtained by calling 1-800-267-2384 or by referring to the CRA’s website: http://www.cra-arc.gc.ca/ebci/haip/srch/advancedsearch-eng.action. Enter the gift amount for each charity in the $ box on the right. 3. If you are giving through payroll, divide your total gift by 26 and enter the amount per pay at the bottom in the ‘Payroll Deductions’ section. 4. Enter the grand total for Box 2 donations. Note: If you choose to give to more than three registered Canadian charities, it is necessary to list the Charities with exact names and the appropriate BN/Registration numbers on a blank sheet of paper and attach it with the Gift form. Also, ensure that the amount per pay and the grand totals reflect all of your gifts.

8. Section 3 – Grand Total and Leadership Giving Please verify that the amounts reported at the top of the gift form are an accurate reflection of the designated amounts in Boxes 1, 2, 3 and 4. In other words, the gift form must balance! In many locations, the names of Leadership Givers are included in a thank you document and/or Honour Roll. If you give at this level, you can choose to not have your name included in the document by ticking the box in section 4 (Please note: The level of leadership giving varies based on the region; for information for your area, please contact your local United Way/Centraide).

9. Section 4 – Method of Payment What is this: In this section you can select several options to make a gift. 1 2 Important 3 Process: 1. Payroll Deduction : If you are selecting the payroll deduction option, simply check the box, indicate the total amount of your gift and proceed to section 6. • 3.Credit Card: If you are choosing to give by credit card, please fill out the appropriate information and submit your form to a Canvasser. • Please indicate your phone numbers in the event we need to get in touch . • Please indicate the type of credit card (Visa, Mastercard, American Express). • Indicate the credit card number and its expiration date. If the expiration date will occur in the following year, your local United Way/Centraide will contact the donor to obtain the new information. • Sign on the signature line. • You must choose between the one-time (1) payment or the twelve (12) monthly payments. If you choose the one-time (1) payment, it will be processed once it is received and verified at your local United Way/Centraide. If you choose the twelve (12) payments, the payment will be taken on the 15th day of each month, starting January of the following year. Important • 2.If you are choosing to give by cash or cheque, please fill out the appropriate information and submit your form to a Canvasser. • Cash: Attach the money to the gift form. • Cheques/Post-Dated Cheque(s): Make all cheques and/or post-dated cheque(s) payable to your Local United Way. Attach them to the gift form.

10. Section 5 - Payroll deductions What is this: Donors making a gift through payroll deduction must fill out this section, but must not detach the section 6 tear-away piece of the form. It will be detached and forwarded to your payroll office by a campaign volunteer after your donation information has been captured by your campaign treasurer. All information that you enter in the section 6 tear-away portion will only be used by the payroll office in your department/agency. Once the information is entered into the system, your finance office will keep the hard copy of the tear-away portion on file. None of the information will be shared with anyone outside of your department/agency. 1 3 2 1. Full Name, PRI, signature of the donor and date: The donor's signature and date of donation is mandatory for all completed gift forms. 2.Verify that the amounts reported at the top of the gift form are an accurate reflection of the designated amounts in Boxes 1, 2, 3 and 4. In other words, the gift form must balance! Also, enter the matching codes (for the United Way) from Boxes 1, 2 and 4 so that the payroll department knows which gifts are going to which United Ways. 3.Indicate how much you wish to donate per pay period (there are 26 pay periods) and the total amount. Ensure that the amount of the donation is divisible into 26 pay periods (for example: $1,000.22 / 26 pays = $38.47 per pay).

11. Thank You !