LA SCCC

Thank you for Giving HOPE to our Louisiana
& supporting the 2021 Louisiana State
Combined Charitable Campaign!

All donors are required to designate to at least one
approved charitable organization from the 2021 LA SCCC Charity List.

(To learn more about the LA SCCC and the participating charities,
please visit www.LASCCC.org)

To make a One-Time Paid Contribution (via bank draft or credit card) please complete the form below:

Contribution Amount

$ 500.00

$ 250.00

$ 100.00

$ 50.00

$ 25.00

$ 10.00

$ 5.00

Other Amount

Other Amount $

Total Amount

LA SCCC One Time Gift

MY INFORMATION

First Name *

Last Name *

Please find your Agency # & Employee Personnel # on your Remuneration Statement (top left corner)

Agency # *

Employee Personnel # *

Street Address

City

State

Zip Code

Email Address *

Phone *

Anonymous

Please keep my gift anonymous

MY DESIGNATION:

Designation #1 *

Designation #1 Amount $ *

Designation #2 (Optional)

Designation #2 Amount $

Designation #3 (Optional)

Designation #3 Amount $

Designation #4 (Optional)

Designation #4 Amount $

“Total Designation Amount” value must equal “Total Amount” of your donation in order to submit your contribution.

Total Designation Amount $

We recommend that you do not use auto-fill to complete the payment section.

Estimations of fundraising and administrative expenses as per the approved 2021 LA SCCC budget is 17%. The actual FRA percentage for the 2021 LA SCCC is contingent upon the final fundraising outcome.

QUESTIONS: please call 225-218-2613 or e-mail sccc@launitedway.org

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MY INFORMATION

MY DESIGNATION:

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