The American Heart Association (AHA) is applying to be a charity listed in the Illinois State Employee Combined Appeal (SECA). In order to qualify, the American Heart Association must obtain 500 electronic signatures from Illinois state employees and annuitants. Please note that your electronic signature does not function as a payroll deduction to the AHA. Your signature only supports the AHA’s application to be an authorized charity in the SECA campaign. Payroll deduction elections for any of the charities occur by a separate process.

The American Heart Association represents itself and the American Stroke Association, a Division of the American Heart Association. The American Heart Association's mission is to build healthier lives, free of cardiovascular disease and stroke. It provides public health education, research funding, professional education/training and community services to the residents of Illinois and throughout the U.S. In fiscal year 2011-2012, the American Heart Association expended no more than 21% of the total collected receipts from all sources for fundraising and overhead services. 79% will support the charity's programs and activities to provide human health and welfare services.

* 2. Please enter your full name.

* 5. Please enter the LAST FOUR Digits of your Social Security Number.

Please note that Section 2500.51 of the Illinois Administrative Code requires certain verification data from employees to be included in this document, including subsection b) 4): “The last four digits of the employee’s or annuitant’s Social Security number.” The AHA will submit the digits to the State and will not use or disclose them for any other purpose.

* 6. By entering your name, you electronically acknowledge reading and understanding the following statement: This is not a payroll deduction authorization. Signing this electronic petition will help the American Heart Association qualify to participate in the Illinois State Employees' Combined Appeal (SECA).

* 7. Please enter today's date.

Date of Signature
For Questions or Concerns Please Contact:
Contessa Gibson
American Heart Association, Mission Workplace Director
208 S. LaSalle Suite 1500 Chicago, IL 60604
Office Line: 312-476-6651