OE2026 - Charity Day - Citizens Bank of the South

Employee Name *

Would you like to participate in the Charity Day program for 2026? *

Local Charity of Choice *First Love KidsChristian Life CenterBaldwin Empty Stocking FundGA Cancer SupportWorking For A Purpose Foundation, IncUnited WayPlease select one or two (max) charities. If you select more than two charities, the first two selected will be used.

*Your donation will be payroll deducted from your paycheck

26x Payroll Deductions of: *

USD

Total Deduction:

$

Donor Confirmation - I choose to participate.

I authorize Citizens Bank of the South to deduct the Charity Day Donation from my payroll check beginning with the 1st payroll of 2024 and continuing until the last payroll of 2024 or the termination of my employment. If employment shall terminate, I will be responsible for the balance at that time.

I also understand that in order to be eligible for the Charity Day, I must make the following annual donation amount: 8 hours of my regular pay or $143.00 ($5.50 per pay period), whichever is greater. By making this donation, if it is the minimum required, it entitles me to one day off with pay that will be coded as a CHARITY DAY.

Employee Signature

OE2026 – Charity Day

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