CONTRIBUTING TODAY WILL MAKE A DIFFERENCE FOR SOMEONE TOMORROW!

To begin or increase your tax-deductible contribution through convenient payroll deduction, simply fill in the below information.

FULL NAME

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* 1. FULL NAME

ASSOCIATE ID #

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* 2. ASSOCIATE ID #

BRAND (select one)

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* 3. BRAND (select one)

I hearby authorize the following to be deducted from my bi-weekly paycheck

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* 4. I hearby authorize the following to be deducted from my bi-weekly paycheck


I understand my contribution to this fund will be used to provide assistance to ascena brand associates in need, in accordance with the established guidelines of this program. This amount will be deducted each pay period and will continue until it is changed or stopped by me.

I authorize my employer, or its service or payroll provider, to make the payroll deductions from these selections. The elections I make will be in effect, unless superseded by law, based on the published pay periods. In the unlikely event of an error, I authorize my employer, or its service or payroll provider, to make adjustments to correct the error.

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* 5.
I understand my contribution to this fund will be used to provide assistance to ascena brand associates in need, in accordance with the established guidelines of this program. This amount will be deducted each pay period and will continue until it is changed or stopped by me.

I authorize my employer, or its service or payroll provider, to make the payroll deductions from these selections. The elections I make will be in effect, unless superseded by law, based on the published pay periods. In the unlikely event of an error, I authorize my employer, or its service or payroll provider, to make adjustments to correct the error.

Today's Date

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* 6. Today's Date

Date / Time

T