To make a contribution, Employees need to complete the attached payroll deduction form Cares Deduction Form Employee Name *Location / DepartmentEmployee #Social Security - Last 4 DigitsRecurring Deduction per week$2.00 $5.00 $10.00 $20.00 Other Amount per week$One-Time Deduction$Hereby authorizeI hereby authorize Juniper to process the deduction selected above from my paycheck as a voluntary contribution to the Juniper Cares Employee Relief Fund and acknowledge the following: I understand my contributions will be deposited and used for purpose of the Juniper Cares Employee Relief Fund. I understand refunds will not be issued on any contributions processed. I understand to stop a recurring deduction at any time I must submit a request in writing to the Juniper Cares Employee Relief Fund email at caresfund@juniperlandscaping.com. I understand requests to stop or start a recurring deduction will be processed in the pay period following the date requested. By submission of my application for considerationBy submission of my application for consideration, I certify that the information in this application is true, complete, and correct. I understand that false answers, statements, or significant omissions made by me shall be sufficient cause for denial of assistance and corrective action. Should my request be approved, I agree to the terms set-forth in this application and related policies and procedures.SignatureDate